St. Margaret Memorial Hospital

Functional neuroimaging studies of the anatomical correlates of familial major depressive disorder (MDD) and bipolar disorder (BD) have identified abnormalities of resting blood flow (BF) and glucose metabolism in depression in the amygdala and the orbital and medial prefrontal cortical (PFC) areas that are extensively connected with the amygdala. The amygdala metabolism in MDD and BD is positively correlated with both depression severity and "stressed" plasma cortisol concentrations measured during scanning. During antidepressant drug treatment, the mean amygdala metabolism decreases in treatment responders, and the persistence of elevated amygdala metabolism during remission is associated with a high risk for the development of depressive relapse. The orbital C metabolism is also abnormally elevated during depression, but is negatively correlated with both depression severity and amygdala metabolism, suggesting that this structure may be activated as a compensatory mechanism to modulate amygdala activity or amygdala-driven emotional responses. The posterior orbital C and anterior cingulate C ventral to the genu of the corpus callosum (subgenual PFC) have more recently been shown in morphometric MRI and/or post mortem histopathological studies to have reduced grey matter volume and reduced glial cell numbers (with no equivalent loss of neurons) in familial MDD and BD. These data suggest a neural model in which dysfunction of limbic PFC structures impairs the modulation of the amygdala, leading to abnormal processing of emotional stimuli. Antidepressant drugs may compensate for this dysfunction by inhibiting pathological limbic activity.

OBJECTIVE: To examine racial differences in the incidence of systemic lupus erythematosus (SLE). METHODS: A population-based registry of SLE patients in Allegheny County, Pennsylvania, was used to identify incident cases of SLE diagnosed between January 1, 1985 and December 31, 1990, from 3 sources, by medical record review (University of Pittsburgh Lupus Databank, rheumatologists, and hospitals). Capture-recapture methods using log-linear models were used to estimate the level of case-finding and to calculate 95% confidence intervals (CI). Incidence rates were calculated per 100,000 population. RESULTS: A total of 191 definite and 78 probable incident cases of SLE were identified, and the overall annual incidence rates were 2.4 (95% CI 2.1-2.8) and 1.0 (95% CI 0.8-1.3), respectively. The crude incidence rates of definite SLE were 0.4 for white males, 3.5 for white females, 0.7 for African-American males, and 9.2 for African-American females. The annual incidence rates of definite SLE remained fairly constant over the study interval. African-American females with definite SLE had a younger mean age at diagnosis compared with white females (P < 0.05). Since the overall ascertainment rate was high (85%; 95% CI 78-92%), the ascertainment-corrected incidence rate for definite SLE, 2.8 (95% CI 2.6-3.2), was similar to the crude rate. CONCLUSION: Our rates clearly confirm previous reports of an excess incidence of SLE among females compared with males and among African-Americans compared with whites. We have used capture-recapture methods to improve the accuracy of SLE incidence rates, and we advocate their use to facilitate comparisons across studies.

OBJECTIVE: To examine the effects of cyclophosphamide (CYC) on the development of malignancies and on the long-term survival of patients with rheumatoid arthritis (RA). METHODS: We used a longitudinal cohort design in which 119 patients (76 women and 43 men) with refractory RA who were treated with oral CYC between 1968 and 1973 were compared with 119 control patients with RA (matched for age, sex, disease duration, and functional class) who were evaluated during the same time period but did not receive CYC. RESULTS: There was increased risk of malignancy in the CYC-treated group, with 50 cancers found in 37 patients in the CYC group compared with 26 cancers in 25 of the control patients (P < 0.05). The relative risk of cancer for those treated with CYC was 1.5 (95% confidence interval 0.93-5.5). Nine of the malignancies in the CYC group were bladder cancers and 19 were skin cancers, compared with no bladder cancers and 6 skin cancers in the control group. The total dose of CYC was higher in those who developed cancer, particularly in those with bladder cancer. Three of the bladder cancers occurred 14, 16, and 17 years after CYC had been discontinued. CONCLUSION: The risk of malignancy, particularly bladder cancer, in RA patients treated with oral CYC continues even 17 years after discontinuation of the drug.

BACKGROUND: There are few reports in the literature detailing arthroscopic treatment of unidirectional posterior shoulder instability. HYPOTHESIS: Arthroscopic capsulolabral reconstruction is effective in restoring stability and function and alleviating pain in athletes with symptomatic unidirectional posterior instability. This population has significant differences in glenoid and chondrolabral versions when compared with controls. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Ninety-one athletes (100 shoulders) with unidirectional recurrent posterior shoulder instability were treated with an arthroscopic posterior capsulolabral reconstruction and evaluated at a mean of 27 months postoperatively. A subset of 51 shoulders in contact athletes were compared with the entire group of 100 shoulders. Patients were evaluated prospectively with the American Shoulder and Elbow Surgeons scoring system. Stability, strength, and range of motion were evaluated preoperatively and postoperatively with standardized subjective scales. Forty-eight shoulders had magnetic resonance arthrograms performed and were available for review. The posterior inferior chondrolabral and bony glenoid versions were measured and compared with controls. RESULTS: At a mean of 27 months postoperatively, the mean American Shoulder and Elbow Surgeons score improved from 50.36 to 85.66 (P < .001). There were significant improvements in stability, pain, and function based on standardized subjective scales (P < .001). The contact athletes did not demonstrate any significant differences when compared with the entire cohort for any outcome measure. The results in the 71 shoulders followed for at least 2 years were similar to the overall group. On magnetic resonance arthrography, the shoulders with posterior instability were found to have significantly greater chondrolabral and osseous retroversion in comparison with controls (P < .001 and P = .008, respectively). CONCLUSION: Arthroscopic capsulolabral reconstruction is an effective, reliable treatment for symptomatic unidirectional recurrent posterior glenohumeral instability in an athletic population. Overall, 89% of patients were able to return to sport, with 67% of patients able to return to the same level postoperatively.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

CONTEXT: DSM17938 has shown promise in managing colic, but conflicting study results have prevented a consensus on whether it is truly effective. OBJECTIVE: DSM17938 effectively reduces crying and/or fussing time in infants with colic and whether effects vary by feeding type. DATA SOURCES: We searched online databases (PubMed, Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, the Database of Abstracts of Reviews of Effects, and Cochrane), e-abstracts, and clinical trial registries. STUDY SELECTION: DSM17398 versus a placebo, delivered orally to infants with colic, with outcomes of infant crying and/or fussing duration and treatment success at 21 days. DATA EXTRACTION: We collected individual participant raw data from included studies modeled simultaneously in multilevel generalized linear mixed-effects regression models. RESULTS: Four double-blind trials involving 345 infants with colic (174 probiotic and 171 placebo) were included. The probiotic group averaged less crying and/or fussing time than the placebo group at all time points (day 21 adjusted mean difference in change from baseline [minutes] -25.4 [95% confidence interval (CI): -47.3 to -3.5]). The probiotic group was almost twice as likely as the placebo group to experience treatment success at all time points (day 21 adjusted incidence ratio 1.7 [95% CI: 1.4 to 2.2]). Intervention effects were dramatic in breastfed infants (number needed to treat for day 21 success 2.6 [95% CI: 2.0 to 3.6]) but were insignificant in formula-fed infants. LIMITATIONS: There were insufficient data to make conclusions for formula-fed infants with colic. CONCLUSIONS: DSM17938 is effective and can be recommended for breastfed infants with colic. Its role in formula-fed infants with colic needs further research.

A clinical randomized study (posttest design) was conducted to examine whether patient-centered care (PCC) impacts patient satisfaction, perception of nursing care, and quality of care. Differences were seen in 2 of 3 subscales within the Baker and Taylor Measurement Scale. The PCC group rated satisfaction (P = .04) and quality of services (P = .03) higher than controls. PCC may impact patients' perception of the level of satisfaction and quality of care received.

PURPOSE: A steep tibial slope may contribute to anterior cruciate ligament (ACL)-injuries, a higher degree of instability in the case of ACL insufficiency, and recurrent instability after ACL reconstruction. A better understanding of the significance of the tibial slope could improve the development of ACL injury screening and prevention programmes, might serve as a basis for individually adapted rehabilitation programmes after ACL reconstruction and could clarify the role of slope-decreasing osteotomies in the treatment of ACL insufficiency. This article summarizes and discusses the current published literature on these topics. METHODS: A comprehensive review of the MEDLINE database was carried out to identify relevant articles using multiple different keywords (e.g. 'tibial slope', 'anterior cruciate ligament', 'osteotomy', and 'knee instability'). The reference lists of the reviewed articles were searched for additional relevant articles. RESULTS: In cadaveric studies, an artificially increased tibial slope produced an anterior shift of the tibia relative to the femur. While mathematical models additionally demonstrated increased strain in the ACL, cadaveric studies have not confirmed these findings. There is some evidence that a steep tibial slope represents a risk factor for non-contact ACL injuries. MRI-based studies indicate that a steep slope of the lateral tibial plateau might specifically be responsible for this injury mechanism. The influence of the tibial slope on outcomes after ACL reconstruction and the role of slope-decreasing osteotomies in the treatment of ACL insufficiency remain unclear. CONCLUSION: The role of the tibial slope in sustaining and treating ACL injuries is not well understood. Characterizing the tibial plateau surface with a single slope measurement represents an insufficient approximation of its three-dimensionality, and the biomechanical impact of the tibial slope likely is more complex than previously appreciated. LEVEL OF EVIDENCE: IV.

We describe injuries to the posterior root of the medial meniscus in patients with spontaneous osteonecrosis of the medial compartment of the knee. We identified 30 consecutive patients with spontaneous osteonecrosis of the medial femoral condyle. The radiographs and MR imaging were reviewed. We found tears of the posterior root of the medial meniscus in 24 patients (80%). Of these, 15 were complete and nine were partial. Complete tears were associated with > 3 mm of meniscal extrusion. Neither the presence of a root tear nor the volume of the osteonecrotic lesion were associated with age, body mass index (BMI), gender, side affected, or knee alignment. The grade of osteoarthritis was associated with BMI. Although tears of the posterior root of the medial meniscus were frequently present in patients with spontaneous osteonecrosis of the knee, this does not prove cause and effect. Further study is warranted.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD systemic treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna). RESULTS: The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain. CONCLUSIONS: Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.

BACKGROUND: Rituximab is a selective, B-cell depleting, biologic agent for treating refractory rheumatoid arthritis (RA). It is a chimeric monoclonal antibody targeted against CD 20 that is promoted as therapy for patients who fail to respond to other biologics. There is evidence to suggest that rituximab is effective and well tolerated when used in combination with methotrexate for RA. OBJECTIVES: To evaluate the benefits and harms of rituximab for the treatment of RA. SEARCH METHODS: We conducted a search (until January 2014) in electronic databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science), clinical trials registries, and websites of regulatory agencies. Reference lists from comprehensive reviews were also screened. SELECTION CRITERIA: All controlled trials comparing treatment with rituximab as monotherapy or in combination with any disease modifying anti-rheumatic drug (DMARD) (traditional or biologic) versus placebo or other DMARD (traditional or biologic) in adult patients with active RA. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias and abstracted data from each study. MAIN RESULTS: We included eight studies with 2720 patients. For six studies selection bias could not be evaluated and two studies were considered to have low risk of bias. The level of evidence ranged from low to high, but was rated as moderate for most outcomes. We have prioritised reporting of rituximab (two 1000 mg doses) in combination with methotrexate since this is the approved dose and most commonly used combination. We also reported data on other combinations and doses as supplementary information in the results section of the review.American College of Rheumatology (ACR) 50 response rates were statistically significantly improved with rituximab (two 1000 mg doses) in combination with methotrexate compared with methotrexate alone at 24 to 104 weeks. The RR for achieving an ACR 50 at 24 weeks was 3.3 (95% CI 2.3 to 4.6); 29% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate achieved the ACR 50 compared to 9% of controls. The absolute treatment benefit (ATB) was 21% (95% CI 16% to 25%) with a number needed to treat (NNT) of 6 (95% CI 4 to 9).At 52 weeks, the RR for achieving clinical remission (Disease Activity Score (DAS) 28 joints < 2.6) with rituximab (two 1000 mg doses) in combination with methotrexate compared with methotrexate monotherapy was 2.4 (95% CI 1.7 to 3.5); 22% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate achieved clinical remission compared to 11% of controls. The ATB was 11% (95% CI 2% to 20%) with a NNT of 7 (95% CI 4 to 13).At 24 weeks, the RR for achieving a clinically meaningful improvement (CMI) in the Health Assessment Questionnaire (HAQ) (> 0.22) for patients receiving rituximab combined with methotrexate compared to patients on methotrexate alone was 1.6 (95% CI 1.2 to 2.1). The ATB was 24% (95% CI 12% to 36%) with an NNT of 5 (95% CI 3 to 13). At 104 weeks, the RR for achieving a CMI in HAQ (> 0.22) was 1.4 (95% CI 1.3 to 1.6). The ATB was 24% (95% CI 16% to 31%) with a NNT of 5 (95% CI 3 to 7).At 24 weeks, the RR for preventing radiographic progression in patients receiving rituximab (two 1000 mg doses) in combination with methotrexate was 1.2 (95% CI 1.0 to 1.4) compared to methotrexate alone; 70% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate had no radiographic progression compared to 59% of controls. The ATB was 11% (95% CI 2% to 19%) and the NNT was 10 (95% CI 5 to 57). Similar benefits were observed at 52 to 56 weeks and 104 weeks.Statistically significantly more patients achieved a CMI on the physical and mental components of the quality of life, measured by the Short Form (SF)-36, in the rituximab (two 1000 mg doses) in combination with methotrexate-treated group compared with methotrexate alone at 24 to 52 weeks (RR 2.0, 95% CI 1.1 to 3.4; NNT 4, 95% CI 3 to 8 and RR 1.4, 95% CI 1.1 to 1.9; NNT 8, 95% CI 5 to 19, respectively); 34 and 13 more patients out of 100 showed an improvement in the physical component of the quality of life measure compared to methotrexate alone (95% CI 5% to 84%; 95% CI 7% to 8%, respectively).There was no evidence of a statistically significant difference in the rates of withdrawals because of adverse events or for other reasons (that is, withdrawal of consent, violation, administrative, failure to return) in either group. However, statistically significantly more people receiving the control drug withdrew from the study compared to those receiving rituximab (two 1000 mg doses) in combination with methotrexate at all times (RR 0.40, 95% CI 0.32 to 0.50; RR 0.61, 95% CI 0.40 to 0.91; RR 0.48, 95% CI 0.28 to 0.82; RR 0.58, 95% CI 0.45 to 0.75, respectively). At 104 weeks, 37% withdrew from the control group and 20% withdrew from the rituximab (two 1000 mg doses) in combination with methotrexate group. The absolute risk difference (ARD) was -20% (95% CI -34% to -5%) with a number needed to harm (NNH) of 7 (95% CI 5 to 11).A greater proportion of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate developed adverse events after their first infusion compared to those receiving methotrexate monotherapy and placebo infusions (RR 1.6, 95% CI 1.3 to 1.9); 26% of those taking rituximab plus methotrexate reported more events associated with their first infusion compared to 16% of those on the control regimen with an ARD of 9% (95% CI 5% to 13%) and a NNH of 11 (95% CI 21 to 8). However, no statistically significant differences were noted in the rates of serious adverse events. AUTHORS' CONCLUSIONS: Evidence from eight studies suggests that rituximab (two 1000 mg doses) in combination with methotrexate is significantly more efficacious than methotrexate alone for improving the symptoms of RA and preventing disease progression.

Thirty-four membranes from 20 cementless and 14 cemented prostheses from 33 patients excised during revision arthroplasty were analyzed for foreign-body reactive processes. As a control, identical analyses were performed using adjacent pseudocapsular tissue taken from 12 patients during revision arthroplasty. Histologically, cementless membranes tended to contain more metal debris, and cemented membranes contained more foreign-body giant cells. Collagenase, gelatinase, prostaglandin E2, and interleukin-1 were measured in conditioned media taken from organ cultures of each interface membrane. Both cementless and cemented membranes released significant levels of gelatinase and collagenase, prostaglandin E2, and interleukin-1 into the conditioned media when compared with control tissues. However, the tissue concentrations were not significantly different between cementless and cemented membranes. Although histologic differences between cementless and cemented interface membranes exist, both share a similar capacity to release bioactive products that can induce bone resorption and cause aseptic loosening of the hip prostheses.

PURPOSE: We wanted to determine whether metformin is an effective medication for treatment of overweight or obese adults who do not have diabetes mellitus or polycystic ovary syndrome (PCOS). METHODS: We searched MEDLINE (1966-2003), EMBASE (1986-2003), Allied and Complementary Medicine Database (1985-2003), International Pharmaceutical Abstracts (1970-2003), the Cochrane Library, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Controlled Trials Register, MEDLINE In-Process & Other Non-Indexed Citations, reference lists of retrieved articles, and articles by selected authors and pharmaceutical manufacturers. Inclusion criteria were being obese or overweight determined by a BMI of 25 kg/m2 or greater or waist-to-hip ratio (WHR) of more than 0.8, metformin use, and aged 18 years or older. Exclusion criteria were a diagnosis of diabetes mellitus, polycystic ovarian syndrome or descriptors of polycystic ovarian syndrome, human immunodeficiency virus infection, and concomitant antipsychotic medications. Trials were graded on an 11-point Jadad scale. Only randomized controlled and blinded trials were accepted. Two reviewers independently extracted data from each trial. Primary outcomes measured were changes in BMI, WHR, and weight. RESULTS: Fifty-seven potentially relevant studies were initially identified; 48 were excluded because of lack of randomization, lack of blinding, failure to meet inclusion or exclusion criteria, inaccessible outcomes, or improper study design. Nine clinical trials met criteria for validity assessment. Four studies used the parameter of waist-to-hip ratio, 3 studies included BMI, and 8 used weight. Two of the 9 studies showed a small reduction in WHR. CONCLUSION: Insufficient evidence exists for the use of metformin as treatment of overweight or obese adults who do not have diabetes mellitus or polycystic ovary syndrome. Further studies are needed to answer this clinical question.

A retrospective study of 79 patients with rheumatoid arthritis was undertaken to determine the incidence of subaxial subluxation after upper cervical fusions. Fifty-five patients had isolated axial subluxation and underwent atlantoaxial fusion. Twenty-four underwent occipitocervical fusion for atlantoaxial subluxation and superior migration of the odontoid. The two groups were comparable in age, duration of disease, and time to follow-up (atlantoaxial fusion, 65.4 months; occipitocervical fusion, 72.6 months). Fusion rates were comparable: 80% atlantoaxial fusion and 90.1% occipitocervical fusion. Of the occipitocervical fusion patients, 36% developed subaxial subluxation requiring surgery at an average of 2.6 years after fusion. Of the atlantoaxial fusion patients, 5.5% developed subaxial subluxation requiring surgery after an average of 9 years after fusion. No patient with atlantoaxial fusion developed superior migration of the odontoid. Subaxial subluxation requiring surgery developed early in patients after occipitocervical fusion. This was not true of atlantoaxial fusion. Early atlantoaxial fusion seemed to prevent the development of superior migration of the odontoid. When occipitocervical fusion is necessary and early subaxial subluxation is present, longer fusions or occipitocervicothoracic fusion should be strongly considered.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD prescription topical treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s). RESULTS: The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus. CONCLUSIONS: For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.

BACKGROUND: Surgical treatment of patellofemoral instability can successfully diminish episodes of subluxation and dislocation, as well as symptoms of pain and instability. HYPOTHESIS: Surgical treatment of lateral patellar instability in a strictly athletic population will facilitate return to sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2004, 41 Fulkerson osteotomies combined with an arthroscopic lateral release were performed in 34 athletes for patellofemoral instability. Three patients were lost to follow-up. All patients participated in sports at least 3 times per week in at least one sport for 4 months of the year. There were 4 male and 30 female patients; 7 patients underwent bilateral, staged procedures. There were 14 high school, 12 collegiate, and 8 recreational athletes. Results were obtained by an independent examiner. RESULTS: The mean age was 20.05 years (range, 14-54 years) with a mean follow-up of 46 months (range, 22-71 months). Patients averaged 1.3 dislocations before reconstruction (range, 0-6). The average Lysholm score was 91.8 (range, 67-100) at follow-up. The International Knee Documentation Committee (IKDC) scores were A (normal) in 27 knees, B (near normal) in 12, and C (abnormal) in 2. Seventeen patients had symptomatic hardware removed at an average of 8 months. There were 2 complications: one saphenous neuroma that resolved, and one recurrent dislocation in a patient later diagnosed with Ehlers-Danlos syndrome. CONCLUSION: This series is the largest to date documenting the successful treatment of patellofemoral instability in athletes with concomitant Fulkerson osteotomy and arthroscopic lateral release. Forty-nine percent of patients in our series required removal of screws from the osteotomy site.

OBJECTIVES: To determine the natural history of infant gastroesophageal reflux disease (GERD) with esophagitis, we periodically analyzed symptoms and biopsies during 1 yr in 19 infants randomly assigned to placebo in a pharmacotherapy study. METHODS: One hundred infants who were referred during 1994-1999 for GERD, were unresponsive to 2-wk life-style measures, and manifested morphometric reflux esophagitis, were assigned at random to one of four treatment arms. This analysis examines the 19 (ages 2.8-6.0 months) assigned to placebo who returned for initial follow-up. SYMPTOMS and esophageal biopsy were assessed at baseline and 2, 4, 6, and 12 months. At any visit with both symptoms and biopsy unimproved, infants were "rescued" to open label active drug. RESULTS: By 12 months, 10/19 completed without rescue; the 9 others withdrew (3) or required pharmacotherapy (6). SYMPTOMS: Among the 10 nonrescued completers, parents' global score rated 9 "completely well," and 1 "improved." Comparing 12-month symptoms to baseline symptoms in the 10 completers, fewer reported regurgitation >3/day, >1 Tbsp, or that was uncomfortable; crying >1 h/d, or during or after feeds; or arching spells or abnormal hiccups (p < 0.05, chi(2)). Biopsy: None of the 10 ever had normal biopsies (basal cell layer <25% and papillary height <53% of epithelial thickness). One had normal papillary height, but abnormal basal thickness. Five others had normal basal thickness, but all five of them had abnormal papillary height. CONCLUSION: Although symptoms improved in more than half of the infants with reflux esophagitis followed longitudinally for 1 yr without pharmacotherapy, histology remained abnormal.

Ninety of 110 consecutive patients with rheumatoid deformities of the cervical spine surgically treated had associated neurologic deficits. Fifty-five patients had atlantoaxial subluxation. In this group, there were 16 Ranawat Class I patients (normal), 21 Class II (weakness, hyperreflexia, dysesthesia), 13 Class IIIA (paresis and longtract findings but can ambulate), and five Class IIIB (quadriparesis and inability to ambulate), After C1–C2 stabilization, 94.8% improved at least one class. Twenty-two patients had AAS-SMO (atlanto-axial subluxation and superior migration of the odontoid) only one before surgery was Class I, five Class II, eight Class IIIA, and eight Class IIIB. Seventy-six percent improved at least one class after surgery. Nineteen had isolated subaxial subluxation (SAS). Three were Class I, two Class II, nine Class IIIA, and five were Class IIIB. After surgery, 94% improved at least; one class end all ware ambulating, Fourteen had combined AAS-SMO-SAS deformities. There ware no Class I patients, only four Class II, four Class IIIA, and six Class IIIB. After surgery, 71% improved. The four deaths that occurred in the immediate postoperative period were Class IIIB. Fifteen patients had worsening or recurrence of their symptoms. Thirteen of these were related to the later development of subaxial subluxation. Neurologic symptoms and recovery were related to severity of the deformity. Those with SMO had greater neurologic deficits and worse results. In general, neurologic recovery is encouraging even in the IIIB patient. Earlier surgery should be done, however, particularly before SMO develops, if possible. Halo immobilization should be used immediately in all IIIB patients because they will get neurologic improvement just with this stabilization before surgery. All patients with neurologic deficits should be immobilized after surgery in a halo. Using this technique very favorable results can be obtained in those patients with rheumatoid deformities and associated neurologic deficits.

During the first 5 years (1981-1985) of the liver transplantation program in Pittsburgh, a total (preoperative, intraoperative, and postoperative) of 18,668 packed red cell units, 23,627 fresh-frozen plasma units, 20,590 platelet units, and 4241 cryoprecipitate units was transfused for the procedures. This represents 3 to 9 percent of the total of blood products supplied by the Central Blood Bank to its 32 member hospitals. Six hundred thirty-six (636) transplants were performed on 485 patients in two hospitals: the Presbyterian University Hospital (564 beds) and Children's Hospital of Pittsburgh (236 beds). All of the blood components used in the operations were procured and released by the Central Blood Bank. This report describes some of these findings.

OBJECTIVES: Despite the burden of disease caused by influenza and pneumococcus, immunization rates are moderate and have not reached national goals set for 2010. This study's objective was to identify patient knowledge, attitudes, and beliefs that serve as facilitators of and barriers to influenza and pneumococcal vaccination. DESIGN: A survey conducted in 2000 by computer-assisted telephone interviewing. SETTING: To encounter a broad spectrum of patients and healthcare systems, we sampled patients at inner-city health centers, Department of Veterans Affairs outpatient clinics, and rural and suburban practices. PARTICIPANTS: Inclusion criteria were patients aged 66 and older and an office visit after September 30, 1998. MEASUREMENTS: Responses to questionnaire. RESULTS: Overall, 1,007 (82%) interviews were completed among 1,234 people contacted by phone. Vaccination against pneumococcal disease was significantly related to being able to accurately describe one or more classic symptoms of pneumonia (P =.05). Vaccination against influenza and pneumococcal disease was significantly related to belief that vaccination was the best way to prevent these diseases (P <.001). The unvaccinated reported that they felt they were not likely to contract influenza and that they did not know they needed the pneumococcal vaccine. Access was not related to vaccination status. CONCLUSIONS: Educational campaigns to increase vaccination rates among older adults should focus on symptoms of, risk for, and severity of influenza and pneumococcal diseases and encouraging physicians to recommend the vaccines to their patients.