Abstracts of scientific papers. (G-O).

Section on Gastroenterology

ALKALIGENES FAECAUS INFECTION OF A PANCREATIC PSEUDOCYST/ABSCESS. Mahilakshmi Aswathnarayanappa, MD, Harold P. Katner, MD, and Rajagopal Chadalavada MD. Medical Center of Central Georgia, Macon, GA.

Alkaligenes faecalis is a gram-negative rod found in the alimentary tract as a saprophyte in 5% to 19% of the healthy population. We report a rare case of A faecalis isolated from an infected pancreatic pseudocyst/abscess. The patient was a 39-year-old man with a history of alcohol abuse who was treated conservatively for acute pancreatitis. He was readmitted twenty days later for worsening symptoms. On examination he was febrile, had decreased breath sounds on the left side and had diffuse abdominal tenderness. Admission laboratory tests showed a normal WBC count and differential, and elevated amylase and lipase levels. Computerized tomography (CT) of the abdomen revealed multiple thickwalled fluid collections around the pancreas. Chest x-ray film showed a left-sided effusion, which was found to be an exudate with 678 WBC/[mm.sup.3], 56% neutrophils, and an amylase level of 143 mg/dL. Treatment with meropenem was started, but he continued to spike fevers and developed a leukocytosis with bandemia. Eight days after admission, a CT-guided drainage of one of the fluid collections was performed. Purulent material was obtained which grew A faecalis. The organism was susceptible to quinolones and resistant to meropenem. The patient was given gatifloxacin therapy. He required surgical exploration, which revealed a necrotic pancreas with multiple abscesses. The patient improved clinically. Petruschky isolated A faecalis in 1896 from human feces. Various observers have implicated A faecalis as a cause of enteric fever, food poisoning epidemics, diarrhea, dysentery, peritonitis, appendicitis, cystitis, chronic suppurative otitis media, meningitis, arthritis, abscesses, and septicemia. To the best of our knowledge, there has been no reported case of this organism infecting a pancreatic pseudocyst or causing pancreatic abscesses. The importance of diagnosing the etiology of an infected pancreatic pseudocyst/abscess cannot be understated. Surgical drainage, along with appropriate antibiotic coverage, is usually necessary to clear these infections.

PREVALENCE OF HEPATITIS C VIRUS ANTIBODIES IN SICKLE CELL PATIENTS. Mohammad Hassan, MD, Oswaldo Castro, MD, and William E. Matory, MD. Center for Sickle Cell Disease, Washington, DC.

The purpose of this study was to determine the prevalence of hepatitis C virus antibodies (anti-HCV) in patients with sickle cell disease. Between 1983 and 2001, 150 patients with sickle cell disease from the Howard University Hospital Sickle Cell Center were screened for HCV antibody (54% women, 46% men, median age, 36 years). Frozen serum samples from 56 adult sickle cell patients who had participated in previous surveys (1983-1992) of HIV and HTLV-l serology were tested in 1992 when commercial ELISA test (Ortho) became available. One hundred thirty two patients had sickle cell anemia (SS), fifteen had sickle C disease (SC) and three had sickle B thalassemia. History of blood transfusion, IV drug abuse, homosexuality, tattooing, iron overload, and alcohol abuse was obtained with chart review. Antibodies to HCV were detected in 53 patients (35.3%). Of the frozen serum samples from 56 patients tested in 1992, 32 (57%) were reactive for anti-HCV. Only 21 of 96 patients (21.8%) who were tested after 1992 tested positive for HCV antibodies. Forty of 78 patients (51.2%) who received more than 10 units of packed red blood cells tested positive for HCV antibody. Only 13 of 60 (21.7%) patients who had received less than 10 units of packed red blood cell transfusion tested positive for HCV antibodies. None of the 12 patients who never received transfusions tested positive for HCV antibody. Twenty patients (25.7%) who were transfused more than 10 units developed iron overload. A total of twelve of these patients with iron overload underwent liver biopsies. Seven of 12 specimens (58.3%) showed significant liver damage. Four of these revealed cirrhosis (33.33%); three had chronic active hepatitis (25%) and five patients (41.7%) had evidence of mild to moderate portal inflammation. The prevalence of HCV antibody and iron overload is directly related to the number of blood transfusions in patients with sickle cell disease. Incidence of HCV infection has decreased significantly since the screening of donor blood for HCV became available. Chronic HCV infection and iron overload could cause significant liver disease in these patients.

A PATIENT WITH WEIGHT LOSS, DIARRHEA AND MUSCLE WASTING-MNGIE SYNDROME. Luis F. Lara, MD, and Joel T. Bruggen, MD. Section of Gastroenterology, Wake Forest University Baptist Medical Center, Winston-Salem, NC.

A 51-year-old man who had a transverse colectomy for "perforation" in 1991 was seen for worsening weakness, weight loss and diarrhea. The patient was worked-up at an outside institution, where a presumptive diagnosis of myasthenia gravis was made. He was treated with pyridostigmine and then azathioprine but had no improvement.

He was seen in 2000 by the neurology service at our institution to evaluate progressive weakness and ophthalmoplegia that was first noticed in 1991. The patient had lost more than 88 lbs since 1991, most of it during the last year. He was complaining of fatigue when chewing, dysphagia to solids more than liquids, generalized muscle pain and lower extremity cramps. There was a remote history of alcohol and tobacco abuse. On physical examination he had abnormal extra-ocular eye movements, with right eye deviation and severe ptosis bilaterally, severe temporal wasting and general muscle atrophy. Differential diagnosis included neuromuscular disease, neuromuscular junction disease, peripheral neuropathy or mitochondrial myopathy. The patient was referred to the gastroenterology clinic. Laboratory test results, including stool studies, were negative. An EGD and colonoscopy revealed a wide-mouth diverticulum in the duodenum and in the terminal ileum. Biopsies were unremarkable. An MRI of the brain showed marked gen eralized leukodystrophy. EMG was consistent with myopathy and peripheral sensory neuropathy was diagnosed. A left deltoid muscle biopsy under light microscopy revealed non-diagnostic changes compatible with neuromuscular degeneration, maybe from previous alcohol abuse. Ragged red fibers were not seen. Electron microscopy showed mitochondrial aggregates with inclusions consistent with a mitochondrial myopathy. A hydrogen breath test was grossly abnormal and the patient was given antibiotics. A small bowel follow-through showed significant small bowel diverticulosis. The diarrhea improved, but the patient continued to lose weight due to poor food tolerance, persistent nausea and vomiting, and dysphagia, and TPN was instituted. A SBFT showed aspiration and poor intestinal transit time. The patient was diagnosed with MNGIE (mitochondrial neurogastrointestinal encephalomyelopathy) syndrome. Coined by Hirano et al, it consists of progressive ophthalmoplegia, ptosis, peripheral sensorimotor neuropathy, muscle wastin g and leukoencephalopathy. GI symptoms include persistent nausea, vomiting, ab1dominal pain, and diarrhea, with significant intestinal dlysmotility leading to recurrent pseudo-obstruction and weight loss. Lactic acidosis after a glucose load has also been described. Skeletal muscle biopsy usually shows the presence of ragged red fibers and enzyme analysis shows decrease activity of respiratory chain enzymes like cytochrome C oxidase. Multiple mtDNA deletions are common and the disease has been mapped to chromosome 22q. Therapy is anecdotal and consists of avoiding vitamin deficiencies, with some advocating the use of thiamine, riboflavin, creatine, and coenzyme Q. Prognosis is poor, with death occurring between the ages of 28 and 58 years.

REVERSAL OF PROGRESSIVE NYCTALOPIA IN A PATIENT WITH CROHN'S DISEASE. Kishore V. Gaddipati, MD, Himabindu C. Chalasani, MD, Jon M. Sweet, MD, and Gerald Schertz, MD. Department of Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA.

Vitamin and nutrient deficiencies are not uncommon in Crohn's disease, with short-bowel syndrome after extensive bowel resection. Diagnosis of these conditions at an early stage is crucial to prevent their progression toward irreversible damage. There is a single report in literature, of reversible night -blindness (nyctalopia) associated with vitamin A deficiency, but this phenomenon is probably under-diagnosed and underreported. A 60-year-old thin Caucasian man with a history of Crohn's disease for more than 20 years who had undergone total proctocolectomy with partial gastric and small-bowel resection (Billroth type II anastomosis) presented with complaints of difficulty driving at night and reading under dim light. He claimed that he saw a "big block of ink-blot with ragged edges" in both eyes, but "can read the clock through it." With bright light, the spot was gone, but "everything had a greenish tinge." He had been having these symptoms for 2 weeks prior to presentation. He had been diagnosed with oste tis fibrosa a year before and had been treated for hypocalcemia on one occasion. He was taking vitamin D, iron dextran, calcium carbonate, omeprazole, vitamin [B.sub.12], and folic acid. Ophthalmologic evaluation revealed a 2/6 score in color-plate reading, but retinoscopy was unremarkable. Serum retinol level wasdrawn, which was 0 (normal,l0-85 [micro]g/dL). Therapy was begun with ICaps (6,600 IU of vitamin A) and 10,000 IU of vitamin A. Over next 3 months, his symptoms gradually improved, and there was a complete resolution of nyctalopia after 5 months. This is the second report of reversible nyctalopia, an extra-intestinal complication of Crohn's disease caused by malabsorption of fat-soluble vitamins due to short-bowel syndrome. Limited studies on this subject in the past have shown that patients with < 80% of ideal body weight (as in our patient), and with serum retinol concentration < 22 [micro]g/dL, run a high risk of night blindness. As 34% of Crohn's disease patients in one study had low dietary vita min A intake but normal serum retinol levels, a high index of clinical suspicion is crucial in recognizing this reversible condition. Although it might not be feasible in primary care practice, electroretinography could be done to demonstrate a flat scotopic response and a diminished and delayed photopic response. Other associated findings, like signs of vitamin D deficiency, could also provide clues. Delayed diagnosis can lead to irreversible loss of vision, as has been widely documented in populations of underdeveloped countries, where vitamin A deficiency is the leading cause of blindness.

PSYCHIATRIC DISORDERS IN PATIENTS WITH CHRONIC HEPATITS C, AN ALARMING ASSOCIATION. Muhamad Aly Rifai, MD, James K. Moles, MD, and Brian Van der Linden, MD, MPH. University of Virginia, School of Medicine, Roanoke-Salem. Veterans Affairs Medical Center, Salem, VA.

It is estimated that 4 million Americans are chronically infected with the hepatitis C virus (HCV). An appreciation of the burden of psychiatric illness in patients with hepatitis C infection is of more than academic interest. Early recognition and treatment of psychiatric disorders in [HCV.sub.+] patients is important to the course and management of hepatitis C, as well as to the psychiatric disorder itself. Newer forms of interferon-2a (IFN) therapy are more effective in the treatment of chronic HCV infection; however IFN therapy is complicated by a host of neuropsychiatric side effects. Active psychopathology may also interfere with compliance, rendering these medications ineffective or precipitating adverse reactions. We assessed the prevalence of psychiatric disorders in a sample of [HCV.sub.+] patients at the Veterans Affairs Medical Center in Salem, Virginia. Medical records of 400 randomly selected [HCV.sub.+] (by ELA II) patients were reviewed for past and present DSM-IV-based psychiatric disorders. A similar group of randomly selected patients who were HCV-negative was utilized as a control. Each psychiatric diagnosis was independently confirmed (by 2 reviewers) with DSM-IV criteria utilizing symptoms recorded in the chart. Only the diagnoses that could be independently confirmed were included for analysis. The prevalence rates of psychiatric disorders in the [HCV.sub.+] vs HCV-negative patients are as follows: Mood disorders, 38% vs 17%; personality disorders, 30% vs 7%; posttraumatic stress disorder, 19% vs 13%; and psychotic disorders, 17% vs 4%. Alcohol abuse/ dependence disorders were found in 86% of [HCV.sub.+] patients vs 23% of HCV-negative patients. Our data indicate that prevalence rates of a variety of psychiatric disorders are higher in patients with hepatitis C than in the control [HCV.sub.-] negative patients in the same health system and the general US population. Mood, anxiety, personality, and psychotic disorders were all relatively common in these patients. Psychiatric disorders may in fluence the course and treatment of hepatitis C infection, and gastroenterologists and psychiatrists should work together to manage the substantial psychiatric comorbidity in patients with this infection. Gastroenterologists should become aware of the substantial psychiatric comorbidities in patients with chronic HCV infection, since they impact its course and treatment. Since newer and more effective treatments of HCV are becoming available, psychiatrists may be asked to help identify patients to be screened for HCV, and manage the psychiatric co-morbidities of patients infected with HCV receiving IFN.

PANCREATIC CANCER MASQUERADING AS GASTRIC CANCER. Montubua F. Vasser-Smith, MD, and Ali R. Rahimi, MD, FACP, AGSF. Department of Internal Medicine, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center in Savannah, GA.

Gastrointestinal malignancies can be devastating. Many are discovered in their terminal stages with debilitating and unusual presentations. A 34-year-old African American man presented with sharp right flank pain radiating to epigastrium. His medical history was significant for gastric ulcer, diagnosed and treated two years before. The patient was jaundiced, with a 25-pound weight loss. Pertinent findings included WBC count of 18,800/[mm.sup.3], total bilirubin level of 19.4 mg/dL, AST level of 187 U/L, ALT of 337 U/L, and alkaline phosphatase level of 506 U/L. An EGD showed a 5-cm ulcerated gastric mass along the greater curvature, with evidence of duodenal and pyloric compression. Several biopsies were taken. CT scan of abdomen and pelvis demonstrated a large gastric mass covering the head of the pancreas and causing obstruction of the common bile duct, with multiple metastases seen in the liver. Surgery was performed. It was felt that the mass represented pancreatic carcinoma with direct extension to the s tomach and liver. The pathology report confirmed the presence of pancreatic adenocarcinoma and CA 19-9 was elevated at 22,000 U/mL. Pancreatic carcinomas are great masqueraders, and attempts should be made to define the pathology in unusual presentations to ensure early diagnosis.

COMMON VARIABLE IMMUNODEFICIENCY AND DIARRHEA. Brian P. Mulhall, MD, and Roy K. H. Wong, MD. Walter Reed Army Medical Center, Washington DC.

A 41-year-old man with the underlying diagnosis of common variable immunodeficiency (CVID) presented for evaluation of progressive diarrhea and weight loss. He described multiple bowel movements each day (up to 20) that were watery, malodorous, and greasy. He had no associated fevers or chills; denied blood or mucus in the toilet bowel; and reported no other systemic complaints, with the exception of a 30-pound weight loss. He had no history of similar complaints. His medical history included only CVID (for which he had received intravenous immunoglobulins monthly for the past three years) and recurrent sinusitis (prior to his diagnosis of CVID). He had previously had sinus surgery and an inguinal hernia repair. He took no additional medications. He did not smoke, and denied sick contacts or recent travel. Examination showed mild wasting, but was otherwise unremarkable. His work-up defined serologic evidence for malabsorption and malnutrition. Stool leukocytes and culture were negative, but Blastocystis homin is was found on three consecutive ova and parasites tests. All other stool studies were negative. A transglutamase test was positive, and small-bowel biopsy showed villous blunting. Colonoscopy and CT of the abdomen were both unremarkable. This patient was treated empirically for B hominis, which can be a pathogen in the setting of immunodeficiency. He improved briefly, but diarrhea recurred. Long-term therapy had decreasing efficacy. After subsequent EGD (results above), the patient was prescribed a gluten-free diet. His IgA and 1gM tests were intermittently positive, but diarrhea was unchanged with a strict gluten-free diet. Villous blunting persisted. Because of the entity of CVID-enteropathy (with villous blunting), the patient was treated empirically with oral prednisone. His diarrhea resolved in 2 weeks. After 6 weeks of therapy, villous blunting had nearly resolved. He was referred to the NIH for enrollment in an IL-2 treatment protocol. Discussion will address the pathogenicity of B hominis, other pat hogens seen in immunodeficiency disorders, and the gastrointestinal conditions unique to immunodeficiency syndromes, which are reasonably prevalent. We will discuss the decision tree analysis for this case and interesting aspects for future research.

Section on Geriatrics

ERYTHROCYTE SEDIMENTATION RATE (ESR) IN ALZHEIMER'S DISEASE AND NON-ALZHEIMER DEMENTIA. Hossein Akhondi, MD, and Ali R. Rahimi, MD, FACP. Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.

Although the differentiation between Alzheimer's disease (AD) and non-Alzheimer dementia has been facilitated by use of cerebrospinal fluid tau protein, amyloid beta 42, and also imaging techniques like SPECT and PET, the need for a fast and economical screening test still exists. After excluding people with other reasons for an elevated ESR, we compared the ESR of AD patients with those with non-AD dementia and a control group. ESR values as high as 19 mm/hr were considered to be in the standard range (regardless of age or sex). AD patients could have either "within the standard" or "elevated". ESR, but it was improbable for non-AD patients to have ESR of less than 19 mm/hr (P < .001). A "within the standard range" ESR in a demented patient seems to favor AD (specificity, 82%; positive predictive value, 89%). ESR is a standard, inexpensive, and rapid laboratory method that has a high predictive value and has potential to play a significant role in distinguishing AD from non-Alzheimer's dementia.

Section on Gynecology

THE HURRIED WOMAN SYNDROME (FATIGUE, WEIGHT GAIN, AND LOW SEX DRIVE) IN GYNECOLOGY PATIENTS: PREVALENCE AND PHYSICIAN ATTITUDES ON CAUSES AND TREATMENTS. Brent W. Bost, MD, MBA, FACOG. St. Elizabeth Hospital, Beaumont, TX.

In order to assess the prevalence of the hurried woman syndrome--fatigue, weight gain, and low sex drive (libido)--among women seeing an obstetrician/gynecologist (ob/gyn) and to determine physician attitudes on cause and effective treatments, questionnaires were mailed to 1,200 fellows of the American College of Obstetricians and Gynecologists (ACOG) randomly selected from the 2000-2001 Directory of Fellows. Surveys returned by fellows who stated that they did not see many general gynecology (GYN) patients were excluded from evaluation. 435 eligible surveys were returned for an overall response rate of 36.3%. The prevalence of fatigue, weight gain, and low libido among nonpregnant patients was reported to be 39.5%, 63.2%, and 34.5%, respectively. More than 64% of the ob/gyns felt that stressful lifestyles (busy careers, hurried schedules, family activities, and other commitments) play a dominant role in causing these symptoms, while another third stated that stress was at least an important causal factor. 73 % of the doctors felt that lowering stress levels would be "very helpful" to women with these three common complaints, while another fourth felt that decreasing stress would be "somewhat helpful" in lessening symptoms. Only 1% of the physicians polled felt that life stresses were unimportant. 58% of the doctors frequently prescribe antidepressants for patients after a negative medical work-up for fatigue, and 76% recommend a balanced calorie-restriction diet for weight loss. 82% of ob/gyns feel that male hormone replacement plays only a minor role in the treatment of low libido, while voting ovcrwhelmingly that stressful lifestyles and relationship problems with partners are the more important causes of a troubled sex life. Fatigue, weight control problems, and decreased libido are common symptoms among women who seek the help of an ob/gyn. Although these symptoms constitute a minor depression, the author proposes the term hurried woman syndrome, as it more accurately reflects the underlying cause of the prob lem while pointing patients toward effective treatment, without the negative connotadon of depression. The physicians surveyed feel that lowering stress through lifestyle changes, as well as diet, exercise, and antidepressant therapy, is effective treatment for this condition, an opinion supported by the current literature.

PREVENTION OF PELVIC ORGAN PROLAPSE, STRESS URINARY AND FECAL INCONTINENCE. Brent W. Bost, MD, MBA. St. Elizabeth Hospital, Beaumont, TX.

To review the available literature to identify risk factors and propose an effective strategy to prevent pelvic organ prolapse, stress urinary incontinence, and fecal incontinence. A computerized literature search of the English language journals published since 1994 was conducted via MEDLINE on the following topics: pelvic organ support and continence mechanisms, pelvic prolapse, stress urinary incontinence, fecal incontinence, complications of cesarean section and vaginal delivery. Relevant articles were evaluated and additional references were identified and evaluated for inclusion. One hundred forty-eight articles were identified by the search engine, but only those with clinical relevance were evaluated further. The proposed mechanisms for injury to the pelvic organs and continence systems were reviewed, and specific risk factors for the development of pelvic organ prolapse, stress urinary incontinence, and fecal incontinence were identified. Long- and short-term complication rates for cesarean section a nd vaginal delivery were also reviewed. Substantive evidence shows that muscle, nerve, and connective tissue injury at the time of vaginal delivery is the most likely cause of stress urinary incontinence, pelvic support problems, and fecal incontinence. Age, the prolonged stresses of gravity, obesity, and the diminishing effectiveness of estrogen exacerbate these injuries and result in stress incontinence and pelvic prolapse in approximately 50% of parous women, while rectal injuries at delivery leave 5% to 15% of these women with inadequate rectal sphincter control. Specific risk factors identified were a strong family history of pelvic prolapse and/or incontinence; a large fetus; prolonged second stage of labor; extensive episiotomy or laceration; increasing vaginal parity; prolonged exposure to oxytocin; operative vaginal delivery; and persistent occiput posterior presentation. Elective cesarean section appears to be protective if performed before labor progresses and is associated with a very low rate of short- and long-term complications. Women must be adequately informed of both the short- and long-term risks of elective cesarean section versus attempted vaginal delivery, and be offered the route of delivery that fits their individual risk preferences. Cesarean section should be strongly considered when two or more risk factors for pelvic organ prolapse and incontinence are present.

ENDOMETRIAL CRYOABLATION. Leonard Weather, Jr., MD. Omni Fertility and Laser Institute, New Orleans, LA.

The purpos of this study was to assess the efficacy and safety of Her Option(CryoGen) endometrial cryoablation. Her Option endometrial cryoblation is a new second-generation endometrial ablative device indicated for menorrhagia as an alternative to hysterectomy. The study was a retrospective analysis of seven cases of endometrial cryoablation. All patients received preoperative endometrial sampling. The procedures were done in an outpatient facility in conjunction with sonography, and there were no complications. The mean follow-up time was six months, and complete resolution or improvement was noted in all cases. Endometrial cryoablation appears to be a safe and effective procedure to treat certain patients with benign causes of menorrhagia who do not desire future pregnancy.

PELVISCOPIC OCCLUSION OF UTERINE VESSELS IN THE TREATMENT OF SYMPTOMATIC LETOMYOMATA UTERI. Leonard Weather, Jr., MD. Omni Fertility and Laser Institute, New Orleans, LA.

The purpose of this study was to evaluate the effects of laparoscopic uterine artery Ligaclip occlusion in treating symptomatic leiomyomata uteri. The study was a retrospective analysis of ten cases of pelviscopic occlusion of uterine arteries. All patients underwent technically successful application of Ligaclip to the uterine arteries without intraoperative complications. Complete resolution of symptoms was noted in seven patients; two had improvement after two months, and one had improvement, but complained of vasomotor symptoms. Pelviscopic occlusion of uterine arteries via Ligaclip application appears to be a capable new method to treat symptomatic leiomyomata uteri

DISPLACEMENT OF A VESICOAMNIOTIC PIGTAIL CATHETER INTO THE MATERNAL INTRA-ABDOMINAL CAVITY Michelle Yvonne Perry, MD, Ramon V. Meguiar, MD, FACOG. Department of Obstetrics and Gynecology, Mercer University School of Medicine, Memorial Health University Medical Center, Savannah, GA.

In utero vesicoamniotic shunts are used in cases of fetal urethral obstruction resulting in dilation of the proximal collecting system. Placement allows adequate draining of urine and restoration of the normal fetal kidney. We present a case of vesicoamniotic shunt placement using a fetal pigtail catheter with subsequent displacement into the maternal intra-abdominal cavity. The 24-year-old, gravida 1 patient was referred to the maternal-fetal medicine service due to a fetal diagnosis of megalourethra/prune-belly syndrome. Ultrasonographic evaluation performed in April confirmed megalourethra, and a pigtail catheter was placed under ultrasonographic guidance. Confirmation of placement was noted. Ultrasonography performed one month later revealed the pigtail catheter to be floating free in the amniotic sac. The fetus again developed signs of prune-belly syndrome with megalourethra and bilateral hydronephrosis. Due to the pliability of the catheter and the low risk of adverse effects, the catheter was left in p lace, with the assumption that it would be expelled with the fetus at the time of delivery. In July, the patient was admitted for induction of labor at 32 5/7 weeks due to oligohydramnios (amniotic fluid volume 2.7 by amniotic fluid index). The patient underwent a forceps-assisted vaginal delivery without expulsion of the pigtail catheter. Manual uterine exploration was performed without finding the catheter. A KUB performed after delivery demonstrated the pigtail catheter projecting over the right sacroiliac joint, with uncertainty as to whether it resided in or outside of the uterus. In August, a second KUB revealed no change in catheter position. In October, a CT scan was performed, locating the catheter anterior to the bladder and immediately posterior to the rectus abdominis muscles. A diagnostic laparoscopy was performed, which showed the pigtail catheter loosely adherent to the anterior parietal peritoneum immediately beneath the right medial umbilical ligament. The catheter was removed gently but easi ly from the anterior abdominal wall. The mechanism by which the catheter migrated is unknown. This case outlines a rare complication of in utero vesicoamniotic shunt placement. When catheter placement is performed, frequent monitoring is needed to track possible migration.

Section on Medical Management and Administration

IVIG THERAPY RESULTS IN POSTINFUSIONAL HYPERVISCOSITY AND PSEUDOHYPONATREMIA ATTRIBUTABLE TO HYPERPROTEINEMIA. Beth A. Steinberger, CPT, MC, USAR, DO, and Teresa A. Coleman, MAJ, MC, USAR, MD. DWIGHT DAVID EISENHOWER ARMY MEDICAL CENTER, Fort Gordon, GA.

IVIG therapy has been increasingly associated with peri-infusional thromboembolic events, possibly due to a hyperviscosity that may occur following IVIG therapy. Hyponatremia has been infrequently reported after IVIG therapy and has been presumed to be due to the glucose moiety complexed with infused immunoglobulin. Pseudohyponatremia is detected by the presence of an osmolar gap and can also occur in states of hyperproteinemia. We hypothesized that WIG therapy may result in hyperproteinemia-related hyperviscosity and pseudohyponatremia, and conducted a prospective observational study to evaluate the incidence of hyperviscosity occurring after IVIG therapy and its relationship to serum sodium, glucose, protein, osmolality and the serum osmolar gap. Eligible study patients received WIG at a dose of 2gm/kg. All patients underwent pretherapy determinations of sodium, glucose, and protein levels; osmolality; and serum osmolar gap. Values were obtained again at 6 and 24 hours, and 10 days after the initiation of t herapy. Values obtained at each time point were compared with pre-IVIG infusion values with paired t tests. The correlations between serum viscosity, sodium, protein, osmolality and the calculated osmolality/osmolar gap were determined at each time point with a stepwise linear regression. Eighteen IVIG infusions were evaluable. Paired-samples t tests revealed a statistically significant increase in serum protein levels and decrease in serum sodium levels 6 and 24 hours after the initiation of IVIG therapy. Twenty-four hours after the completion of IVIG therapy, the serum viscosity significantly increased. In a multivariate analysis, hyperproteinemia at the 6-hour time point predicted hyponatremia (P < .001). Hyperproteinemia at the 24-hour time point remained a statistically significant predictor of serum hyperviscosity (P = .024). The decrease in calculated serum osmolality was strongly correlated with an increase in the osmolar gap (P = .002) at the 24-hour time point. These data demonstrate that transient hyperviscosity and pseudohyponatremia occur following WIG therapy due to significant hyperproteinemia. We postulate that this hyperviscosity may contribute to the thromboembolic phenomena being reported with WIG therapy, and that inappropriate treatment may exacerbate this hyperviscosity. To our knowledge, this is the only study to definitively document hyperviscosity and hyponatremia following IVIG therapy, and to explore its possible mechanisms.

TRANSCRIPTION, TECHNOLOGY AND ROI. Julianne Weight, Tarzana, CA.

Documentation is a significant part of a physician's practice. Although most physicians dictate and have these records transcribed, many do not have sufficient understanding of the practices utilized in an industry with no standards. For physicians who outsource transcription services, the presentation will review service stability and qualifications, billing practices, and hidden charges and costs. The relationship between billing and adequate documentation will be reviewed. Although physicians are reluctant to incur transcription costs, there is a direct relationship between increased and better documentation and reimbursement and denied claims. The legal significance of the medical record will be reviewed. Technologies in speech recognition and digital dictation for physicians and transcriptionists will enable both to lower costs by increasing productivity through technology Some products will be showcased.

Section on Medicine

A CASE OF ABDOMINAL COMPARTMENT SYNDROME. Parag Bharadwaj, MD, and Subramanyam Chittivelu, MD. Amarillo, TX.

The purpose of this study was to enhance the knowledge about the early recognition of abdominal compartment syndrome (ACS). A 72-year-old Caucasian man was initially admitted to the medical ward with urosepsis. Three days later he was transferred to the ICU because of altered mental status, abdominal distension, abdominal tenderness, lactic acidosis, and hypoxia. Upon arrival to the ICU, the patient was intubated for acute hypoxemic respiratory failure. Treatment with W fluids, dopamine, and broad-spectrum antibiotics was begun. Abdominal x-ray films did not reveal any obstruction or perforation. Surgical consultation was obtained to rule out ischemic bowel. Emergency exploratory laparotomy was performed. Bowel ischemia, peritonitis, and perforation were absent, and about 1500 cc of ascitic fluid was removed. The abdomen was closed using transfascial suturing of the incision. Gram stains and cultures of ascitic fluid were unrevealing. Postoperatively, the patient's abdomen became tense due to rapid distension , and urine output diminished to the anuric range. We suspected ACS based on physical examination, anuria, and shock. Elevated urinary bladder pressures (29 mm Hg) confirmed the diagnosis of ACS. Re-exploration of the abdomen was not performed, due to the patient's poor condition and his family member's request. He died the next day. In our patient, ACS occurred due to sepsis, ileus, and abdominal closure technique. ACS can occur due to trauma to the abdomen and pelvis, massive fluid resuscitation, shock, ileus, ascites, retroperitoneal hemorrhage, peritonitis, forced closure of the abdomen, and other causes. To track the development of ACS, the intra-abdominal pressure is monitored by measuring urinary bladder pressure. Elevated bladder pressure (25 mm Hg) is diagnostic of ACS. Diagnosis of ACS is usually delayed in medical intensive care units due to the lack of familiarity, infrequent monitoring of bladder pressure, and lack of knowledge of the technique itself. Treatment of ACS includes surgical decompres sion and correction of the cause. Morbidity and mortality rates from ACS are high.

PROTECTION OF HUMAN SUBJECTS IN CLINICAL RESEARCH: THE PITFALLS IN CLINICAL RESEARCH. Dipak P. Pandya, MD, and Jay K. Dave. Baltimore, MD.

Clinical trials are an important part of medical care. Research must be done with good faith, good conduct, and good intention. Using a suitable approach is part of research practice, which favors protection of research subjects. "Good clinical practices" are being promulgated as a universal approach towards protection of the human subject's rights. Appropriate scientific design, good performance, better analyses, monitoring credible data with the dignity and confidentiality of the research subject all contribute to "good clinical practices." The first step (and maybe most important step) toward protection of the research subject is to obtain informed consent in the appropriate way, which identifies respect, beneficence, and justice for the enrolled research subjects.

RECURRENT EPISODES OF ASEPTIC MENINGITIS INDUCED BY DIFFERENT NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDs), INCLUDING ROFECOXIB. Mahilakshmi Aswathnarayanappa, MD, and Harold P. Katner MD, FACP, FIDSA. Medical Center of Central Georgia, Macon, GA.

Aseptic meningitis is caused by viruses, drugs, and connective tissue disorders. We present a patient who had recurrent episodes of aseptic meningitis from three different NSAIDs, including rofecoxib. Our patient is a 28-year-old woman with a history of Sjogren's syndrome who first presented in 1997 with complaints of headache, neck pain, confusion, fever, nausea, vomiting, photophobia, and blurred vision after taking naproxen for a week. Her cerebrospinal fluid (CSF) had 540/[mm.sup.3] white blood cells, with a neutrophilic predominance, elevated protein, and elevated pressure. She presented in 1999 with similar complaints after taking ibuprofen for one week, and was diagnosed with NSAID-induced meningitis. Again in December 2001 she developed similar symptoms after taking rofecoxib. During all three episodes, the patient had CSF pleocytosis, elevated CSF protein level, and elevated CSF pressure. Other studies on the CSF, including Gram stain, bacterial culture, VDRL, cryptococcal antigen, pneumococcal antig en, acid-fast bacilli smear and culture, India ink stain and herpes PCR all returned negative. Symptoms were relieved on all three occasions after discontinuation of the drug. Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. A 1999 literature review reported less than 200 cases worldwide. Major causative agents include NSAIDs, antimicrobials, intravenous immunoglobulins, monoclonal antibodies, intrathecal agents, and vaccines. Though drug-induced aseptic meningitis due to various classes of NSAIDs in the same patient has been reported, it is a rare occurrence. Our patient developed this problem with three different NSAIDs, including the selective cyclo-oxygenase-2 (COX-2) inhibitor. It is important, therefore, to question patients who present with aseptic meningitis about NSAIDs use. NSAID-induced meningitis may recur with the use of different classes of NSAIDs, including COX-2 inhibitors.

AN UNUSUAL CAUSE OF SHORTNESS OF BREATH. Mangla S. Gulati, MBBS, and Thersa Lorch, MD. Baltimore, MD.

A 24-year-old woman with no significant medical history presented as an outpatient complaining of a productive cough and progressive dyspnea for three weeks. She did not respond to two courses of outpatient antibiotics, thereby necessitating admission. Review of her medical history revealed an abortion two weeks before, and pneumonia successfully treated as an outpatient two years earlier. She was using an oral contraceptive, did not use any herbal medications, denied smoking, alcohol or illicit drug use, and worked as a security guard. Her examination was remarkable for tachycardia, tachypnea, and a [pO.sub.2] of 94% on room air, with diffuse inspiratory crackles over both lower lung fields. A chest x-ray film revealed a diffuse bilateral interstitial pattern. Laboratory findings were significant for a [pO.sub.2] of 65 mm Hg, LDH of 500 U/L, and ESR of 94 mm/hr. All serologic tests were negative. The patient failed to improve, despite treatment for both community-acquired and atypical pneumonias. A high-reso lution chest CT scan showed extensive bullous disease and paraseptal emphysema extending to the lower lobes. An infectious etiology was excluded, and bronchoscopy was nondiagnostic. An open lung biopsy showed infiltrates involving the pleura, intralobular septa, and bronchovascular bundles, composed of histiocytes with abundant foamy cytoplasm, consistent with a diagnosis of Erdheim-Chester disease. Fifty-nine cases of Erdheim-Chester disease have been reported in the literature, with only twelve cases of pulmonary involvement. Erdheim-Chester disease is a rare, non-Langerhans cell histiocytosis that presents with extraskeletal manifestations. Affected organs include the kidneys, skin, eyes, retropentoneum, and lungs. This is predominantly a disease of middle-aged males, and both the pathology and etiology are poorly understood. The most common causes of death are respiratory and cardiac failure. Successful therapeutic interventions have not been described. Our patient had no evidence of extrapulmonary involv ement at. the time of diagnosis. Twelve months later, she presented with an acute deep vein thrombosis and significant pulmonary hypertension. We believe this to be the first documented case of isolated pulmonary Erdheim-Chester disease.

A CASE OF VERTEBRAL ARTERY DISSECTION AFTER SIT-UPS. CPT Wesley A. Clarkson, MC, USA, and COL Alan W. Halliday, MC, USA. Brooke Army Medical Center, San Antonio, TX.

Extracranial vertebral artery dissection has been reported in cases of minimal head or neck trauma, including sneezing, coughing and abrupt rotation of the head. There have been no cases reported of this lesion after doing sit-ups, which can produce significant strain on the neck. We report the case of a 38-year-old active-duty physician reporting to the emergency department with a complaint of ataxia. He complained of a persistent, moderate to severe occipital headache, and neck pain after doing sit-ups approximately 1 week earlier. On the day of admission, he woke and had an unstable gait, tending to fall to the right. Physical examination was also significant for right miosis, ptosis, right facial dysesthesia, and right-beating nystagmus while looking to the left. There was no noticeable decrease in sensation to light touch. Upon standing, he had notable truncal ataxia Contralateral pain and temperature was not checked. He was evaluated by the neurology service, and MLRI stroke protocol of head and neck was ordered. MRI/MRA showed evidence of right posterior vertebral artery dissection, with acute occlusion near the C1 level. He was admitted for anticoagulation therapy. The neurologic symptoms resolved except for continued mild ptosis. He was taking oral anticoants at the time of discharge. Extracranial vertebral artery dissections have been reported after minimal trauma. This patient presented with Wallenberg syndrome, or lateral medullary syndrome, which can be a sequela of such a lesion. This case was most likely instigated by sit-ups, as suggested by the onset of symptoms related to doing sit-ups. After reviewing the English literature, this appears to be the first case of vertebral artery dissection related to sit-ups, and may have significant importance to US Army, which is currently reviewing whether to continue the full sit-up as part of the standard physical fitness test.

THE EFFECT OF THE IMPLEMENTATION OF A HOSPITALIST PROGRAM ON LENGTH OF STAY AND COST AT A VA HOSPITAL. M. Carmina C. Garcia, MD, Celso T Ebeo, MD, Ryland P. Byrd, Jr., MD, Richard Jordan, MD, and Thomas M. Roy, MD. The Veterans Medical Center, Mountain Flome, TN, and the Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Although hospitalists were not officially recognized until 1996, there had already been a small number of physicians with similar roles scattered throughout the United States as early as the 1980s. In 1998, the number of practicing hospitalists was estimated to be about 3000 to 4000, with an estimated potential hospitalist workforce of about 19,000. With the heightened demands of managed care, hospitalists are being increasingly used for inpatient care. It has been hypothesized that if physicians were not distracted by outpatient duties, then they could concentrate on the care of hospitalized patients, and thus there would be an improvement in the quality of patient care, as well as a reduction in cost. Our goal was to determine the effects of implementation of a hospitalist program on the length of stay and cost per admission of patients at a Veterans Affairs Medical Center. In 1999, the Internal Medicine service implemented a hospitalist program at the Veterans Affairs Medical Center. A retrospective analys is of the top 20 admission diagnoses to the medical services was therefore undertaken for comparison between the years 1998 and 1999. The top diagnoses and average length of stay for each of those diagnoses were generated through the VA electronic medical records system. Adjustments for inflation were undertaken so that the cost per admission would not be automatically favor 1998. The cost per admission for each year of the study was adjusted for inflation to 2001 dollar amounts. There were approximately 7,500 admissions to the medical ward teams during the 2-year study. Overall, the average length of stay was decreased. Likewise, the overall cost per hospitalization was decreased. An estimated amount of $360,643.00 was saved in 1999 due to implementation of the hospitalist program. Patients admitted in 1999 had shorter average lengths of stay and overall lower average costs per admission compared with patients admitted in 1998. Hospitalist programs, therefore, appear to be a viable model for cost reduction a t Veterans Affairs medical centers.

THE IMMUNONEUTRALIZATION OF PROCALCITONIN (ProCT) IN MORIBUND SEPTIC PIGS IS AS THERAPEUTICALLY EFFECTIVE AS VERY EARLY TREATMENT. K. Becker, MD, PhD, M. Edwards, MD, J. Martinez, MD, E. Nylen, MD, R. Snider, PhD, B. Muller, MD, and J. White, MD. Department of Surgery and Endocrine Division, VAMC, and George Washington University, Washington, DC, and University Hospital, Basel, Switzerland.

A model of highly virulent sepsis was developed in pigs (cecotomy followed by intraperitoneal instillation of 1 g/kg cecal contents, plus 1,012 CFU Esclzericlzia coli). Sepsis was induced in 25 castrated male Yorkshire pigs (25-30 kg), after which three treatment arms were studied: 1) early therapy with a one-hour intravenous infusion of rabbit anti-porcine ProCT IgG given simultaneously with the induction of sepsis; 2) late therapy with the same anti-porcine IgG administered after the third hour, when the animals were moribund; and 3) septic controls that received nonimmune rabbit IgG, either at the early (n = 8) or the late (n = 5) time period. The septic controls all died by 11 hours. They exhibited progressive hypotension, oliguria, decreased cardiac output, and lactic acidemia. In contrast, 86% of animals receiving early therapy and 80% of those receiving late therapy survived until euthanasia at 15 hr. Prior to the time of sacrifice (t = 15 hr), arterial blood pressure (ABP), cardiac index (CI), serum c reatinine (Cr) level, urine output (UOP), pH, and lactic acid (LA) level were measured. There were no significant differences in any parameters measured between those treated early versus those treated late. Furthermore, there was a minor trend toward improvement in some parameters (Cr, pH, and LA) in animals that underwent late therapy in comparison with those having early therapy. These findings further support a potential efficacy of such therapy in humans, perhaps even if sepsis is recognized late in the course of this disease, when physiologic and metabolic parameters begin to deteriorate.

THYROTOXIC PERIODIC PARALYSIS (TPP) IN A BLACK MAN. Jeri Mao, MD, T. G. Oliver, MD, and S. T. Wingo, MD. William Beaumont Army Medical Center, El Paso, TX.

TPP is an uncommon clinical condition usually associated with thyrotoxicosis and, occasionally, is the presenting complaint. It is usually seen in young Asian males and resembles, clinically, other forms of periodic paralysis. 14 cases have been reported in blacks. We describe a case of TPP in a black man following I 131 therapy. A 48-year-old black man with recently diagnosed Grave's disease, who had undergone I 131 therapy 6 weeks previously, presented to the emergency department with acute-onset, profound muscle weakness of all extremities. One day prior to .presentation, he was diagnosed with radiation thyroiditis, as [T.sub.4] and [T.sub.3] levels increased, and he was treated with prednisone and Tapazole. Later, he developed muscle pain and cramping in all extremities, which progressed to paralysis. Review of systems was negative, as was all other medical history. Physical examination was unremarkable at admission. Notable laboratory values were: [K.sup.+], 2.7mEq/L; [PO.sub.4], 2.1 mg/dL; normal calciu m, magnesium, and CPK values. KCL was given. His symptoms began to improve prior to his arrival to the ED, and had completely resolved within 12 hours. Potassium level had normalized within 6 hours. At follow-up, 3 weeks later, he was asymptomatic with a normal [K.sup.+] level. TSH level was < 0.01 [micro]IU/mL with [T.sub.4] level of 0.67 [micro]g/dL. He was treated with levothyroxine, and reported no recurrence of TPP. TPP is reported predominately in Asian males. Hypokalemia and paralysis are the hallmarks of the syndrome, but hypophosphatemia and hypomagnesemia are commonly noted. Eukalemia has been reported. The EKG changes include ST-segment depression with T wave flattening, sinus tachycardia, and U waves. Sinus arrest, sinoatrial block with Wenckebach block, and second-degree atrioventricular block also have been described with TPP. Tapazoleinduced paralysis has not been reported. Although long-term steroid use may cause steroid myopathy, this is unlikely after 1 dose. The precise pathophysiology rema ins unclear, but it likely involves defects in membrane-hound NA, KATPase, which differs from other periodic paralyses where a calcium channel is felt to be the problem. Some reports implicate hyperinsulinemia or an increased level of Na+, K+-ATPase activity. Therapies include KCl and propranolol.

EPIDEMIOLOGY, APPROPRIATENESS, AND COST OF VANCOMYCIN USE IN A MILITARY MEDICAL CENTER Jeri Mao, MD, Jennifer C. Thompson, MD, Dan Miller, CPhT, and Mary S. Ballogg, PharmD. William Beaumont Army Medical Center, El Paso, TX.

Vancomycin use has been increasing dramatically in the past decade, and this has been associated with an increasing prevalence of vancomycin-resistant enterococci. Several factors may explain this nationwide increase in the use of vancomycin. Multidrug-resistant, gram-positive organisms have become dominant nosocomial pathogens, and this has led to the increasing use of vancomycin for prophylaxis or as part of empiric regimens. Widespread evidence shows a significant proportion of vancomycin use was inappropriate when judged by Hospital Infection Control Practices Advisory Committee (HICPAC) criteria. We conducted a retrospective review of the records of patients who were prescribed vancomycin during the year 2000. HICPAC criteria were used to define the indications for use as prophylaxis, empirical, and specific therapy. Appropriateness of vancomycin use was determined by comparing clinical, laboratory and microbiologic data to HICPAC criteria. Results: A total of 173 patients were studied. 111 were male, 62 were female. The majority of patients were elderly (> 57 years old). 80% of patients were discharged home. Prophylaxis use was 17%, empiric use was 45.6% and specific therapy was 37.4%. The longest mean duration of vancomycin therapy occurred in surgical ICU. The duration of hospitalization was longer in the inappropriate-use group. Among prescriptions that were felt to be inappropriate, an alternative drug was available in 51%, and therapy was prolonged in 41%; there was no clear indication for vancomycin in 8% of cases. There were no associations between sex, age, ward, and hospital outcome, and inappropriate vancomycin use. Longer hospitalization was associated with inappropriate vancomycin use (P = .014). Conclusion: At our institution, 69% of vancomycin use was appropriate. Most of the inappropriate use was failure to switch to alternative drugs. Potential saving is estimated at $12,460 if there were no inappropriate use. Age, sex, and PCN allergy status were not risk factors for inappropriate vancomyci n use. Longer hospitalization is a risk factor for inappropriate vancomycin use. We recommend implementation Drug Use Evaluation, prospective monitoring and target education for providers

PAGE KIDNEY: A REVERSIBLE CAUSE OF HYPERTENSION. Paresh Jadav, MD, and Pranay Kathuria, MD. The University of Oklahoma College of Medicine--Tulsa Tulsa, OK.

Page kidney is a rare and unique form of reversible hypertension mediated by extrinsic compression of renal parenchyma as a result of perinephric or subcapsular hematoma. Manifestations of Page kidney include renal ischemia and a state of hyperreninemia, leading to hypertension. Due to the reversible nature of this entity, it represents a potentially curable form of hypertension. Page kidney commonly occurs in previously healthy individuals, and presents as new-onset hypertension in the context of blunt trauma, usually in the remote past. Other etiologic factors include abdominal surgery, warfarin therapy, renal biopsy, anesthetic blocks, renal transplantation, tumor, or isolated, spontaneous onset. We document here an acute presentation of Page kidney following a renal biopsy in a patient being evaluated for hematuria and albuminuria. We also discuss the anatomic basis of Page kidney, diagnostic modalities, therapeutic options, and pertinent references. Page kidney represents an unusual form of hypertension, due to the potential reversibility of this condition. Therefore, the importance of recognizing this condition in the differential diagnosis of new-onset hypertension cannot be overemphasized, as prompt diagnosis and therapy result in full and complete recovery.

SPONTANEOUS THROMBOSIS OF UPPER EXTREMITIES (PAGET-SCHROETTER SYNDROME). Hossein Akhondi, MD, Ali R. Rahimi, MD, FACP, AGSF, David Bigatel, MD, and Edwin W. Grimsley, MD, FACP. Memorial Health University Medical Center, Savannah, GA.

Spontaneous thrombosis of veins draining upper extremities venous systems was postulated by Sir James Paget in 1875. It was, however, Von Schroetter who first related the clinical syndrome to thrombotic occlusion of the axillary and subclavian veins. We are reporting a case of spontaneous subclavian vein thrombosis in an otherwise healthy young man with weightlifting as a hobby. To our knowledge, this is the first case of Paget-Schroetter Syndrome secondary to weight lifting. A 17-year-old otherwise healthy adolescent presented to MHUMC with a three-day history of swelling, pain, and discoloration of the right upper extremity. His examination, other than cyanosis of the finger, swelling, mild pitting edema, and dilatation of colateral vein of the upper arm and anterior chest wall was unremarkable. The laboratory findings were unremarkable, with no evidence of coagulopathy or hypercoagulable state. X-ray film, CT scan, and subsequent venography of right upper extremity revealed thrombosis of right subclavian v ein, with no evidence of thoracic inlet or outlet obstruction. The patient was treated with continuous local thrombolysis. Post-thrombolytic venography revealed resolution of thrombosis. Subclavian vein attained 70% patency. Anticoagulation with Coumadin started and was planned to continue for 3 to 6 months. Paget-Schroetter syndrome is a relatively rare condition. It is unexpected and has dramatic presentation, usually in otherwise healthy young individuals. Effort thrombosis was first coined by Drapanos in 1966. This syndrome usually occurs 24 to 48 hours after unusually strenuous use of the arm and shoulder. Our patient is an amateur weight lifter who practices on a regular basis, and recently has been practicing rigorously. Since Paget-Schroetter syndrome generally occurs in young, active individuals, the major goal of therapy is to minimize the likelihood of significant symptoms of venous insufficiency.

CLINICAL CORRELATION BETWEEN EFFECTIVE ANTICOAGULANTS AND RISK OF STROKE: ARE WE USING EVIDENCE-BASED STRATEGIES? Ali R. Rahimi, MD, FACP, AGSF, Bobby A. Wrights, MD, Hossein Akhondi, MD, and Christian M. Richard, MSc. Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.

The role of anticoagulation therapy in prevention of stroke in patients with nonvalvular atrial fibrillation (AF) is well known. Despite extensive evidence, anticoagulation therapy is not fully utilized. We reviewed the hospital records of 206 patients with nonvalvular AF between calendar years 1997 and 2000. Of the total study sample, 124 patients were taking Coumadin and 160 patients were not. Of those, 91 patients suffered thromboembolic stroke. We used the international normalized ratio (INR) to report the intensity of anticoagulation. The average age for patients taking Coumadin was 72.95 [+ or -] 10.6 years, and was not statistically different from those not receiving Coumadin (74.23 [+ or -] 11.9 years) (P = .232). The mean INR values for patients taking Coumadin was 2.51 [+ or -] 2.03, which is significantly greater (P= .001) than for those patients not receiving therapeutic doses of Coumadin (1.19 [+ or -] 0.45). Of interest is the pattern of Coumadin prescription by physician specialty. Cardiologist s were 4.5 times more likely (P= .035) to prescribe Coumadin than noncardiologist physicians. Neurologists (P = .305) and internists (P = .770) had similar patterns of prescribing Coumadin to patients with atrial fibrillation with the highest rate of thromboembolic events. Although the beneficial impact of preventive anticoagulation therapy is well established, it seems this strategy is underutilized, and physicians in our study employ different patterns of anticoagulation therapy in their patients.

Section on Neurosurgery

IS OCCIPITAL HYPOXIA THE PRINCIPAL MECHANISM OF BILATERAL BLINDNESS IN POSTERIOR LEUKOENCEPHALOPATHY? Daniel Dube, MD, Michael Puruckherr, MD, and Jeffrey Summers, MD. Johnson City, TN.

A 46-year-old white woman presented to the emergency department with mental status changes, nausea, and vomiting. Her boyfriend had found her unresponsive the previous night, but did not call the emergency medical service (EMS). A half-empty bottle of temazepam was found beside her. Her son found her in an obtunded state the following afternoon and called the EMS. The patient's family reported that the boyfriend had previously attempted to strangle her. She was semiconscious and irritable. Glasgow Coma Scale score was 10/15. Her speech was slurred. She had pen-orbital bruises bilaterally. The neck was tender but there was no nuchal rigidity. Vitals signs were a temperature of 98.6[degrees] F; blood pressure, 169/126 mm Hg; heart rate, 110 beats/min; and respiratory rate, 19 breaths/min. Pupils were slowly reactive to light and accommodation. Left and right pupillary diameters were 8 and 6 mm, respectively. Fundi were unremarkable There was left-sided facial droop, and reduced movement and hypotonia in the lef t upper extremity. Lower extremities exhibited reduced motion. The abdomen was diffusely tender to palpation. The rest of the examination was unremarkable. A CT scan of the head showed increased T-signal intensity in the occipital and parietal lobes. MRI of the brain showed lesions reminiscent of vasogenic edema in the occipital and parietal regions in a parasagittal distribution and in the midbrain. MRA of the brain was unremarkable. EEC showed diffuse, generalized slowing. WBC count was 16,800/[micro]L. Hemoccult test of the dirt under her fingernails was positive for blood. Urine and blood cultures, comprehensive metabolic panel, drug screen, alcohol level, thyroid stimulating hormone level, amylase value, lipase level, and chest and abdominal x-ray films were unremarkable. She slowly regained full consciousness, but was noted to have bilateral blindness that progressively resolved over a 5-day period. The inappropriate response of the boyfriend, the previous history of violence, and the clinical picture l ed us to suspect strangulation as the cause of symptoms and clinical findings. We reported the case to the sheriffs office. Bilateral blindness associated with posterior leukoencephalopathy has been reported in malignant hypertension, preeclampsia, posterior circulation hemorrhage, and in post-hypoxic or -anoxic states. Petechial hemorrhage and a resultant local capillary leak is hypothesized to be the etiology. The reasons for the increased susceptibility of the posterior cerebral circulation to hypoxia are not well understood, but are likely to be related to the anatomy and unique regional vasomotor regulation. To our knowledge, this is the first case of strangulation-induced posterior leukoencephalopathy associated with bilateral blindness. The finding of bilateral blindness following an unexplained episode of unconsciousness should alert the physician to the possibility of temporal circulatory cessation. In appropriate situations, this may have forensic implications.

Section on Occupational and Environmental Medicine

GULF WAR ILLNESS: FACT OR FICTION? Roscoe C. Young, Jr., MD, MSPH, Edna W. Lockert, PhD, and Cheryl L. Lockert, MD. Meharry Medical College, Nashville, TN.

By the end of the Gulf War, approximately 697,000 US troops had been deployed to Southwest Asia. Ninety thousand veterans seeking care at federal health care facilities were complaining of unexplained symptoms consisting of chronic fatigue, rash, headaches, anthralgias, myalgias, amnesia, insomnia, and attention deficit. The federal Persian Gulf Veterans Coordinating Board explained the majority of symptoms on the basis of diagnosable diseases, while approximately 23% fell into the category of Gulf War illness (GWI). Other coalition allies (Britain, Canada, and Saudi Arabia) reported GWI in their deployed troops, and similar illnesses have been described in previous wars elsewhere. Post-traumatic stress disorders (PTSDs) have been a constant feature in every armed conflict. In GWI, brain damage and neurologic symptoms may have been caused by "toxic synergism," the combined use of pyridostigmine bromide (PB) tablets, a nerve gas protective agent for all troops in theater, and the insect repellents DEET and per methrin together (but not separately). "Toxic exposure sign," a physical finding on oral examination, consisting of a papillitis on the periphery of the tongue, has been found in some patients, but it is not diagnostic. Exacerbations of asthma and chronic obstructive pulmonary disease have occurred. Desert storm pneumonitis (Al Eskan disease) is a recently described hyperergic condition due to inhalation of hazardous dust. Smoke inhalation from 600 burning oil wells and internal combustion engines contributed to the respiratory hazard. Low-level exposure to chemical warfare agents from destruction of weapons storage bunkers at Khamasiyah and/or An Nasiriyah, may have been responsible for other neurologic symptoms. Sabot armor-piercing rounds of depleted uranium (DU) with mutagenic and teratogenic potential have been hazardous to salvage crews. Viscerotropic leishmaniasis, falciparum malaria, amebiasis, and pulmonary brucellosis have occurred in US troops. Contemporary problems dictate the need for viable heal th plans with both preventive and treatment agendas. It is noteworthy that intense anxiety was related to fear of bodily injury during Gulf War deployment. Among a contingent of Army Reserve nurses anticipating mobilization, forms of separation anxiety, financial and other psychosocial concerns predominated. Bioterrorism fears became compounded with incomplete anthrax vaccination, as the vaccine was in short supply and protective values versus harmful effects were controversial. In forward-deployed units, when psychiatric help was not available, the chaplain was effective in counseling and in rendering pastoral services. The authors predict that repetition of GWI is a distinct possibility in the present war on terrorism wherever our forces are deployed in future conflicts. Anticipation by federal health agencies with a functional plan, coordinated with local government and private health care providers to prevent, diagnose, and treat future veterans is essential.

Section on Oncology

CANCER IN THE FIRST YEAR OF LIFE. Andrea Graudy, MD, Valdesha Ball, Mohammad Hussain, MD, Hernan Correa, MD, and Raj Warrier, MD. LSU HSC/Children's Hospital, New Orleans, LA.

This study reviews the incidence, type of cancer, and outcome of tumors in the first year of life at Children's Hospital from 1983 to 2001. Outpatient and inpatient records, pathology material, Children's Oncology Group records and tumor registry data were reviewed. Sixty-two cases were recorded in this time period. 45 charts were available for review. 63% of the infants were males, and 37% females; 31% were black, and 69% were white. Neuroblastoma and brain tumors were the most predominant cancers in this age group. Overall survival rate was 72%. Family history of cancer was noted in 34% of cases. Rates of mortality and morbidity in children less than one year of age with cancer appeared to be higher than those in the older age groups. The significance of positive family history in increased mortality and morbidity needs to be further studied.

SIGNIFICANCE OF ENROLLMENT IN CLINICAL TRIALS IN MINORITY CHILDREN WITH ACUTE LYMPHATIC LEUKEMIA. Rachael Turn, BS, Jarelle Morgan, BS, and R. P. Warner, MD. Louisiana State University Health Science Center, New Orleans, LA.

This study reviews the incidence of cancer in minority children, compares the types of cancers and participation in clinical trials, and assesses the outcome of cases in minority children. A retrospective study of all cases of cancer seen at Children's Hospital from 1988 through 1998 was performed. Inpatient and outpatient records, POG flow sheets and tumor registry were accessed. ALL was reviewed in detail, due to the large number of cases and the availability of POG protocols during the whole study period. Incidence, types of cancers, and overall survival in childhood cancers were similar for Caucasians and minorities. Minorities and Caucasians with ALL had statistically similar survival results when registered on open POG studies. When children were not entered in POG studies, white children had survival results that were not significantly different than if they were registered. Minorities, on the other hand, had a statistically significant decrease in survival if not enrolled in open studies. Minority chi ldren not enrolled in open protocol studies for ALL have poorer outcomes. The reason for this and for their not being enrolled in studies needs to be looked at in depth.

EXAMINATION OF YEAST ELONGIN C: AN ATTEMPT TO DEFINE FUNCTION AND RELATE TO VON HIPPEL-LINDAU DISEASE. J. McGee, MD, E. Kwon, BS, S. Ghosh, BS, A. Chachulska, PhD, T. Jackson, MD, PhD, W. H. Baricos, PhD, B. Jaffe, MD, and L. E. Hyman, PhD, Tulane University Health Sciences Center, New Orleans, LA.

Von Hippel-Lindau (VHL) disease is a rare autosomal dominant, multi-organ cancer syndrome responsible for a variety of tumors, including renal cell carcinomas, central nervous system hemangioblastomas, and pancreatic cysts. At the molecular level, the VHL tumor-suppressor protein partners with a small, 112-amino-acid protein, Elongin C, which binds an additional protein, Elongin B. The Elongin pair, together with the CUL2 and RBX1 proteins, forms a tetrameric unit characterized as a mammalian E3 ligase, targeting proteins for ubiquitination and subsequent degradation. Of interest with regard to the VHL protein is the highly conserved Elongin C. Despite its eukaryotic homologues found in rats, flies, worms, and yeast, Elongin C has no known specific function. In yeast, Elongin C (Elc1) is a nonessential gene without obvious phenotype difference in its absence. Attempting to define Elc1 function and further relate to precise VHL tumor-suppression mechanisms, we examined yeast (Saccharomyces cerevisiae Elongin C through a series of genetic transformations and directed mutagenesis. One of our studies explored the expression of Pcl6, an Elc1-associated protein identified in previous studies. The relationship between Pcl6 expression in a wild-type Elc1 strain versus Pcl6 expression in an Elc1 deletion strain was defined via Western blot analysis. Semiquantitative survey revealed a marked reduction (about 70% reduction) of Pcl6 protein in the Elc1 null strain compared to the wild-type Elc1 strain. With reintroduction of Elongin C into the Elc1 deletion strain there was restoration of Pcl6 levels comparable to wild-type Pcl6 levels, suggesting that the presence of Elc1 positively influences binding-protein stability. Additionally, human Elongin C was reintroduced into the Elc1 deletion strain and also found to restore Pcl6 protein levels to that of wild- type levels. To confirm our observation of Elc1's role in stabilization of associated proteins, we mutated yeast Elongin C in a putative Pcl6 binding site. Indeed, the m utation of Elc1 resulted in decreased Pcl6 levels. As a result of our findings, we conclude that yeast Ecl1 serves as a stabilizer of its binding partners. Although mammalian Elongin C has been implicated in protein degradation, like other proteins it may have multiple functions. Previous research demonstrated that mutations in VHL within the Elongin C binding domain resulted in the degradation of the VHL protein. Therefore, our studies in yeast support the concept that Elongin C may be required for VHL stabilization and ultimate optimal tumor suppression.

RETROSPECTIVE ANALYSIS OF BREAST CANCER AMONG YOUNG AFRICAN AMERICAN FEMALES. Maria Arsyl De Jesus, Mihoko Fujita, Kyungsook Kim, and Alfred Goldson. Howard University Hospital, Washington, DC.

The purpose of this study was to evaluate the patterns of failure, relapse-free survival, and overall survival among African American breast cancer patients younger than 40 years. We retrospectively reviewed the records of 124 breast cancer patients younger than 40 years who were registered with our cancer database between 1990 and 1999. Ninety-eight percent of these patients were premenopausal, and 28% had a documented family history of breast cancer. Seventy percent of the tumors were 5 cm or less in greatest dimension. Thirty-six percent of the patients had pathologically involved axillary nodes. Surgery was a component of treatment for 98% of the patients. Forty-four percent underwent mastectomy while 53% had breast-conserving surgery. Fifty-six percent of the patients received adjuvant radiation therapy, while 51% were treated with adjuvant chemotherapy. Median follow-up time was 35 months (range, 4-126 months). Locoregional-only first-failure rate was 6%, while systemic failure occurred in 20% of these patients. The 5-year overall survival for these patients was 70%, with relapsefree survival being similar. Patients with early-stage disease were noted to have 5-year survival rates between 74% and 100%. Those who presented with locally advanced or metastatic disease had dismal 5-year survival rates between 0% and 29%. Multivariate analysis using the Cox proportional hazard model identified the presence of metastasis as a factor that significantly affects survival in these young African American females. These results show that African American females younger than 40 years, with early-stage breast cancer managed appropriately, have local control and survival rates comparable to that of the general population. In contrast, young African American females with stage III or IV disease appear to suffer a worse prognosis. However, a larger series of African American females with breast cancer, followed for a longer period, will be required to confirm a negative trend in survival.

Section on Orthopaedic and Trauma Surgery

LONG-TERM RESULTS OF TRAPEZIOMETACARPAL SILICONE ARTHROPLASTY. Hari P. Bezwada, MD, John B. Webber, MD. Department of Orthopaedic Surgery, MCP-Hahnemann, Philadelphia, PA.

Trapeziometacarpal (TMC) joint arthritis can be severely disabling. Resection of the trapezium and implantation of a flexible silicone arthroplasty has been one of several treatment options. Previous authors have reported complications, including synovitis, implant fracture, and subluxation, with its use. From 1975 to 1990, 90 TMC silicone arthroplasties were implanted in 85 patients. We used a technique in which the trapezium was excised and a tendon strip of the flexor carpi radialis was used for balancing and stabilization. Preoperative and postoperative range of motion, grip strength, key pinch strength, tip pinch strength, and radiographs were recorded. Subjective assessments of patient satisfaction were also recorded. Follow-up time averaged 17 years (10-25 years) with a 10-year minimum. 62 implants in 58 patients were available for follow-up. 86% (50/58) patients reported satisfactory results with good/excellent pain relief and function. Grip strength increased by 45% (13.2 kg to 19.1 kg), key pinch st rength increased by 60% (2.4 kg to 3.8 kg), and tip pinch strength increased by 19% (2.1 kg to 2.5 kg). Preoperatively, 34% (21/62) of thumb tips were able to touch the palmar base of the little finger. That improved to 84% (52/62) postoperatively. Subluxation was apparent in 19% (12/62) of implants, with little clinical significance. However, implant fracture occurred in 5% (4/62), and required revision. Finally, silicone synovitis necessitating implant excision was not present in any of the implants (0/62). Silicone arthroplasty appears to be a reliable and worthwhile option for treating disabling TMC arthritis when using this technique. It has demonstrated good patient satisfaction and function, along with excellent pain relief. We have also demonstrated significant improvements in objective criteria with a low incidence of subluxation, implant failure, and synovitis.

THE VARUS-HYPEREXTENSION KNEE: DISTAL AVULSION OF THE LATERAL AND POSTEROLATERAL STRUCTURES OF THE KNEE WITH CONCOMITANT INJURY TO THE CRUCIATE LIGAMENTS, A CLINICALLY IDENTIFIABLE AND REPAIRABLE PATTERN OF KNEE INJURY. Timothy S. Bollom, MD. University of Florida, Shands Hospital, Gainesville, FL.

Acute and chronic injury to the posterolateral corner of the knee is one of the most challenging of all knee-instability patterns treated by the orthopedic surgeon. However, if identified early, successful results could be anticipated. Specifically, varus-hyperextension injury to the knee has been noted to produce grade 3 injury to the posterolateral aspect of the knee in a consistent pattern. The purpose of this review was to identify the mechanism of injury and delineate the predictable pattern of capsular tearing and concomitant cruciate ligament injury. In a review of lateral and posterolateral injuries to the knee treated at our institution since 1993, sixteen patients were identified with a varus-hyperextension mechanism. History and, in some cases, videotape were used to identify the exact mechanism of injury. In all cases, patterns of injury were determined by MRI, recorded intraoperative examination, and surgical and arthroscopic findings. All sixteen patients sustained grade 3 injuries to the latera l and posterolateral corner of the knee, characterized by grade 3+ opening to varus stress, 1 to 2+ posterolateral instability at 30 degrees of knee flexion, and 1 to 2+ opening with varus stress at 0 degrees. Fifteen of these cases were noncontact injuries. Surgical and/or MRI findings in all 16 cases revealed complete avulsion of the lateral collateral ligament and biceps femoris off the fibular head, and avulsion of the deep lateral and posterolateral capsule of the knee off the tibia. Minimal intrasubstance damage to these structures occurred. Two patients sustained tears of the popliteus tendon and two extended tears into the iliotibial band. Complete tearing of the ACL occurred in 13 of 16 patients, with one additional partial tear. Six patients sustained additional injury to the PCL, but only one complete tear. A study of this pattern of injury has lead us to conclude that a varus load applied to the extended knee causes injury by distal avulsion. Continued application of a hyperextension force can the n cause tears to the ACL, with further load causing damage to the PCL. Early recognition is critical, as acute repair of these structures can be easily achieved eliminating the potential long-term sequelae often seen in untreated posterolateral knee injuries.

COMPARISON OF POSTEROLATERAL LUMBAR FUSION RATES OF GRAFTON AND OP-1 IN AN ATHYMIC RAT MODEL. David A. Bomback, MD, Jonathan N. Grauer MD, Roberto Lugo, BA, Nancy W. Troiano, MS, Tushar C. Patel, MD, and Gary E. Friedlaender MD. Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT.

The purpose of this study was to compare the posterolateral lumbar spine fusion rates of two different osteo-inductive products in an athymic rat model. The two products tested were Grafton (a demineralized bone matrix product [DBM]), and osteogenic protein-1 (OP-1, also known as BMP-7). Many osteoinductive bone graft substitutes are entering the clinical arena. However, limited data is available to allow direct comparison of their efficacy. In order to draw such comparisons with relative ease, animal models are used. The athymic rat model has been validated and advocated to minimize inflammatory responses to xenogenic or differentially expressed proteins. We compared the fusion rate of Grafton putty (Osteotech, Inc, NJ), a clinically available and commonly used DBM product, to that of OP-1 putty (Stryker Biotech, Hopkinton, MA), an individual recombinant human BMP being introduced to the clinical setting. This direct head-to-head comparison has not previously been performed. Single-level intertransverse proc ess fusions were performed at the L4-L5 level of sixty 8-9 week-old athymic nude rats (rnu/rnu). Thirty rats were implanted with OP-1 putty alone, and thirty rats were implanted with Grafton putty alone. The dose for these products was 2 mLl/kg, consistent with the Grafton dosing used in rats in previous studies. Half of the animals from each group were sacrificed at three weeks, and the other half at six weeks. Resultant fusion masses were assessed by radiography, manual palpation, and histology. There were no complications. At three weeks, manual palpation of the thirty animals sacrificed revealed a 13% fusion rate in the Grafton group and 100% fusion rate in the OP-1 group. At 6 weeks, manual palpation of the other thirty animals sacrificed revealed fusion rates of 39% in the Grafton group and 100% in the OP-1 group. Of note, one or two adjacent levels were fused in all animals in the OP-1 study groups, whereas no adjacent levels were fused in the Grafton groups. Radiographs were 89% sensitive and 91% spec ific for determining fusion. Histologic analysis is ongoing. This is the first study to directly compare a BMP product with a DBM product. A striking difference between the ability of Grafton and OP-1 to induce posterolateral lumbar fusion in the athymic rat model was found. The methods used here also offer a potential means of comparing other commercially available osteoinductive agents to allow for more educated use of such products in the future.

IS THE ABSENCE OF THE OSSIFIC NUCLEUS PROGNOSTIC FOR AVASCULAR NECROSIS AFTER CLOSED REDUCTION OF DDH? Brian Carney, MD, David Clark, DO, and Christin Daniels, BS. Shriners Hospital for Children, Lexington, KY.

Forty-eight hips in 45 children without associated disease who underwent successful closed reduction of developmental dysplasia of the hip (DDH) at the Shriners Hospitals for Children in Lexington, Kentucky, between January 1, 1989, and December 31, 1999, had at least 2-year follow-up. Medical records were reviewed for sex, side, use of skin traction, age at reduction, and length of follow-up. Radiographs were reviewed. The presence or absence of the ossific nucleus (ON) on the prereduction AP radiograph was noted. Avascular necrosis (AVN) was noted as present if there was evidence of Bucholz and Ogden grade II, III, or IV on the postreduction AP radiographs. There were 8 boys and 37 girls. There were 15 right and 33 left hips. The mean age at reduction was 9.5 months (range, 1-35 months). Traction was used for 21 hips and not used for 27 hips. The ON was present prereduction in 24 hips and was not present in 24 hips. Reduction was reported as gentle and stable; casting was reported as without forced abductio n; and although repeat casting was performed, there were no repeat reductions. The mean length of follow-up was 74 months (range, 24-147 months). AVN was noted postreduction in 14 hips. There was a statistically significant difference in age at time of reduction for children with regard to the ON. The mean age of children with the ON present undergoing reduction was 11.8 months; the mean age of children without the ON present undergoing reduction was 7.2 months. Statistical analysis revealed that sex, side, age at reduction, and use of skin traction was not related to the presence of AVN. Six of the 21 hips (28.6%) that had prereduction traction demonstrated AVN. Nine of 27 hips (33.3%) that did not have prereduction traction demonstrated AVN. Statistical analysis revealed a significant difference between hips that had the ON present at reduction versus those that did not with regard to postreduction AVN. Three of 24 hips (12.5%) that had the ON present demonstrated AVN. Twelve of the 24 hips (50%) that did n ot have the ON present demonstrated AVN. The presence of the ON on prereduction radiograph appears prognostically favorable regarding the absence of AVN on postreduction radiographs.

EARLY VERSUS DELAYED FIXATION OF PELVIC RING FRACTURES. Geoffrey S. Connor, MD, Gerald McGwin, Jr., PhD, Jorge Alonso, MD, and Loring W. Rue III, MD. Department of Surgery and the Center for Injury Sciences, University of Alabama at Birmingham, Birmingham, AL.

This study reports variable outcomes after early and delayed surgical stabilization of fractures of the pelvic ring in terms of pulmonary complication, length of hospital stay, anc cost of hospitalization. The houstpital courses of 151 patients, who sustained acute fractures of the pelvic ring between June 1996 and December 2000 were reviewed. Patient demographics, Injury Severity Score (ISS), timing of operative fixation, and the incidence of pulmonary complications were analyzed. Radiographs were reviewed and fractures classified according to the modified Tile system. Patients who underwent fixation within one week of injury (n = 103) were compared with those in whom surgery was delayed (n = 48). Average ISS was higher among the delayed fixation group (22.7 vs. 19.6), although the differences in fracture patterns between the two groups were not statistically significant. Adjusting for the ISS, when compared with patients having delayed operative fixation, those with early repair had a lower incidence of pul monary complications (12.6% vs. 25.2%) a reduced length of hospital stay (12.7 days vs. 25.0 days), and overall reduced cost of care ($54,400 vs. $133,653). Pelvic ring fixation within the first week of injury results in significantly reduced incidence of pulmonary complication, hospital stay, and cost of care, regardless of injury severity or fracture classification. The coordinated team approach to ensure prompt resuscitation, stabilization, and operative fixation results in the more optimal patient outcomes.

PROSPECTIVE RANDOMIZED CLINICAL TRIAL OF CORALLINE HYDROXYAPATITE (CHA) WITH AUTOGENOUS GROWTH FACTORS (AGF) VERSUS ILIAC CREST BONE GRAFT (ICBG) FOR THE TREATMENT OF SKELETAL NONUNIONS AND DEFECTS. Gary Davis, MD, Joseph Rudd, Jr., PhD, Peter Nowotarski, MD, and Brent Norris, MD. University of Tennessee College of Medicine, Chattanooga, TN.

Nonunion of skeletal injuries can be challenging to treat. The application of bone graft is often warranted. Significant morbidity can be associated with the harvest of a bone graft. Alternatives to bvone grafting should be sought. This study is to determine if CHA/AGF is as efficacious as ICBG for the treatment of skeletal nonunions/defects. A prospective, randomized clinical trial comparing CHA/AGF and ICBG for the treatment of nonunion was conducted. clusion criteria included clinical and radiographic diagnosis of nonunion or a known skeletal defect. Exclusion criteria included known musculoskeletal infection, significant osteoporosis, and laboratory test abnormalities. Serial clinical and radiographic examinations were obtained on all patients.

Important preoperative and postoperative variables were collected, including financial data. Of thirty-one nonunions, 22/31 (71%) were previous open fractures. Seventeen patients were randomized to ICBG. At latest follow-up, 23/31 (74%) patients were healed. Mean time to union: clinical, 10.3 weeks; radiogaphic, 13.6 weeks. Mean time from injury to treatment was 40 weeks. The ICBG group experienced three postoperative nonunions and the AGF group had five. No difference was noted between groups for rate of union, clinical time to union, radiographic time to union, VAS pain at injury site, or financial costs. Significant difference was seen at VAS pain donor site. CHA/AGF does not appear as effective as ICBG for treatment of skeletal nonunions, especially in the tibia. CHA/AGF may have a role in treatment of nonunion without skeletal defect or in locations other than the tibia.

SECOND GENERATION CERAMIC-ON-CERAMIC TOTAL HIP ARTHROPLASTY: RESULTS OF TWO HUNDRED CONSECUTIVE HIPS. Christian M. DuBois, MD, John M. Keggi, MD, Laurine Zatorski, MD, and Kristaps J. Keggi, MD, Department of Orthopaedics, Yale University School of Medicine, New Haven, CT.

Ceramic-on-ceramic coupling is theorized to be superior to metal-on polyethylene coupling with regard to wear debris generation and osteolysis in THR. Mechanical complications, such as fractures and loss of fixation, were frequent with early generations of implant designs. Two new second generation ceramic-on-ceramic prostheses are currently undergoing FDA-sanctioned trials in the US. We report the results of 200 consecutive cementless ceramic-on-ceramic THRs using one of these designs. During a 4-year interval, a single surgeon performed 200 consecutive primary ceramicon-ceramic THRs. This represented 24% of all primary THRs performed during that time interval. A modified anterior surgical approach was used for all procedures. 138 unilateral and 31 1-stage bilateral THRs were performed in 127 male and 42 female patients. The average patient age was 51.2 years. All procedures were performed using the same press-fit hemispherical cup in compination with a press-fit femoral stem. The articular surfaces were com posed of 28-mm (31), 32-mm (165) and 36-mm (4) ceramic heads and liners. The average operative time was 66 minutes for unilateral and 129 minutes for 1-stage bilateral procedures. Diagnoses included osteoarthritis (78%), avascular necrosis (15%), DDH (4%), and post-traumatic arthritis (3%). Clinical outcome was measured using the Harris Hip Scale (HHS). Average follow-up time for all patients was 12.6 months; however, the patients with the first 50 and the first 100 hips in the series had average follow-up times of 25 months and 18 months, respectively. Average preoperative HHS was 39. Average postoperateive HHS improved to 93 at 6 weeks, 98 at 6 months, and 100 at both 2 and 3 years. There were no complications related to the ceramic components themselves. Complications included 3 calcar fractures requiring wire augmentation, 2 dislocations, and 1 case each of nondisplaced calcar fracture, wound hematoma, and nontfatal pulmonary embolus. There were no cases of fixation loosening, migration, or articular surf ace or loss of the locking mechanism. No patient has required revision surgery for any reason. We have observed no mechanical complications in this series of THRs done using an implant system with ceramic-on-ceramic coupling. We are encouraged by the excellent clinical results at short-term follow-up. The clinical efficacy and durability of these THRs will need to be further substantiated with longer follow-up.

THE EFFECTS OF MEDIALIZING CALCANEAL OSTEOTOMY UPON ACHILLES TENDON STRAIN AND FOOT PRESSURES. Mark H. Hadfield, MD, John Snyder, BS, Peter C. Liacouras, BS, John R. Owen, PE, Jennifer Wayne, PhD, and Robert S. Adelaar, MD. Department of Orthopedic Surgery, Medical College of Virginia-Virginia Commonwealth University.

Posterior tibial tendon insufficiency, or adult-acquired flatfoot deformity, involves collapse of the longitudinal arch with ensuing changes in the bony architecture of the foot. While it is generally accepted that a medializing calcaneal osteotomy (MCO) is a very useful treatment for restoring the fallen arch, questions regarding the effects of this procedure upon plantar foot pressures and Achilles tendon length changes need to be answered. This study focused upon changes in plantar foot pressures and Achilles tendon length subsequent to performing a MCO. Fourteen fresh frozen cadaver legs were used to gather Achilles tendon and foot pressure data. Distance variable resistance transducers (DVRTs) were anchored in ventromedial, dorsomedial, dorsolateral, and ventrolateral positions of the Achilles tendon, 2 cm proximal to the Achilles tendon insertion on the calcaneus. Plantar foot pressures were acquired simultaneously using the Tekscan HR MAT. Axial loading (100 lbs) of each specimen was performed in neutr al and dorsiflexion (15 degrees). There was no significant increase in Achilles tendon length as a result of the MCO. Foot pressure data showed that average pressure over the 1st and 2nd metatarsal regions of the forefoot decreased significantly after MCO, while the average pressure over the lateral heel increased significantly. At the same time, there was a significant increase in peak pressures over the medial and lateral aspects of the heel and over the lateral aspect of the forefoot. The finding that pressure decreased over the medial forefoot coupled with increased pressures over the lateral heel suggests that the Achilles tendon is now acting as an inverter of the foot due to the medial shift of the calcaneus. The finding that no significant length changes were found in the Achilles tendon can be interpreted to signify that no increase in strain within the Achilles tendon is incurred subsequent to MCO.

ROOFING BARRIER SHEET TECHNOLOGY ACHIEVES AN EQUIVALENT ANTI-FIBROTIC EFFECT TO HYALURONAN AFTER LAMINECTOMY. Bill Huang, MD, Jennifer Massie, MS, Alexander Giurea, MD, Robert Sah, MD ScD, Steven Garfin, MD, and Wayne Akeson, MD. Departments of Orthopaedics Bioengineering, VA Medical Center and UCSD Medical Center, San Diego, CA.

Epidural fibrosis may contribute to failed back surgeries. The purpose of this study was to compare the antifibrotic effect of a 70:30 poly(L-lactide-co-D,L-lactide) barrier sheet (Macropore) to a hyaluronan (HA) gel, to examine the incisional wound integrity after treatment over 3-week and 8-week periods. Eighty Spragne-Dawley rats had an L5 and L6 laminectomy with unilateral L5-6 disk injury and were sacrificed at 3 and 8 weeks. There were 4 groups: 1) control, unoperated; 2) untreated; 3) HA gel; and 4) barrier sheet. Specimens were analyzed biochemically for total collagen content in the dura, or histologically with Masson-Goldner Trichrome to assess collagen distribution. Surgical incisions were analyzed by uniaxial tensile testing to determine ultimate force, strain, and prefailure stiffness. Statistics were performed using ANOVA. Grossly and histologically, only the untreated laminectomy scar became more adherent to the dorsum of the dura mater from 3 weeks to 8 weeks.

Total collagen content increased significantly in the untreated 8-week group compared with the untreated 3-week group. HA and the barrier treated groups had significantly reduced total collagen content at both time points. The mechanical properties of incisional wound increased significantly between 3 weeks and 8 weeks. The ultimate strength, stress, strain, and stiffness of untreated, HA, and barrier groups were similar within each time point. HA was chosen because it has been shown to decrease cutaneous scar formation in several models. The roofing barrier sheet, by walling off the overlying muscle, may mitigate cellular trafficking and vascular ingrowth into the postlaminectomy defect. Additionally, mechanical testing of the healing incison was performed to address the concern of possible delayed wound healing in previous clinical antifibrotic therapy studies. This study supports the hypothesis that HA and barrier sheet treatment each significantly reduced postlaminectomy scar formation without affecting t he integrity of the incisional wound.

SHORT-TERM FUNCTIONAL OUTCOME OF ARTHROSCOPIC ROTATOR CUFF REPAIR (RCR): A PROSPECTIVE, MATCHED COMPARISON TO MINI-OPEN REPAIR. Lana Kang, MD, R. Frank Henn, ScB, Robert Tashjian, MD, and Andrew Green, MD. Department of Orthopaedics, Brown University and Rhode Island Hospital, Providence, RI.

Arthroscopic rotator cuff repair is being performed with increasing frequency. Among the presumed advantages are less surgical morbidity and earlier return of function. These claims have never been proven. The purpose of this study was to compare the early functional outcome of mini-open and arthroscopic RCR. This was a prospective study of 127 patients with small- and medium-sized rotator cuff tears that underwent mini-open (n = 76) or arthroscopic (n = 51) RCR by a single surgeon. Outcome was assessed at baseline (preoperatively), and at 3 and 6 months postoperatively with physical examination, visual analog scores (VAS) for pain, function, and quality of life, the Simple Shoulder Test, the Disability of Arm, Hand, and Shoulder test, and the SF-36. Changes from baseline were calculated. All demographic variables and baseline outcome parameters were similar. A greater proportion who underwent mini-open RCR had medium-sized tears. The only outcome parameter that was statistically significant was the 3-month c hange in the functional VAS score in favor of mini-open RCR. All other changes in outcome parameters at 3 and 6 months compared to baseline showed no significant difference. The theoretical advantages of arthroscopic RCR have launched this technique into widespread orthopaedic practice. However, scientific data that arthroscopic repairs have a better outcome is lacking. Our study showed no functional difference at 3 and 6 months. There may be benefits of arthroscopic RCR earlier than 3 months that our study did not detect. We plan to compare durability and integrity of repair over time with long-term follow-up.

THE ROLE OF THE BASEMENT PLATE IN PHYSEAL BAR FORMATION. Amanda W. Marshall, MD, Orthopedic Surgery Department, Carolinas Medical Center, Charlotte, NC

The physiologic cause of physeal bar formation after fracture is unknown. A better understanding of the physiologic cause of bar formation may lead to improved methods of treatment or prevention of physeal bars. Forty-nine skeletally immature female Harlan Sprague-Dawley rats were randomized to one of four groups after proximal tibia physeal fracture: I = control = fracture alone; II (RC) = fracture + scraping of resting cells; III (BP) = fracture + drilling of basement plate, and IV (HC) = fracture + drilling of hypertrophying cells. At days 21 and 56, radiographs were evaluated for leg-length discrepancy (LLD) and bar formation. Histologic samples were evaluated for presence of a bar. Day 21 data revealed a significantly greater frequency of histologic and radiographic bars in both the resting cells (RC) and basement plate (BP) groups compared with controls. At day 56 analysis, the BP group demonstrated a significantly higher rate of histologic and radiographic bar formation compared to controls. There was no significant difference in any groups in LLD at day 21. However, by day 56, a significant difference emerged between the LLD of control vs. RC and BP groups, as well as a significant difference between RC and BP. Animals with penetration of the basement plate had more growth disturbance and physeal bar formation than other groups. Injury to the resting cells also caused some growth disturbance, although not as severe as drilling of the basement plate. It appears that the integrity of the basement plate is important for continued physeal growth after fracture, warranting further investigation.

BIOMECHANICAL COMPARATIVE ANALYSIS OF TIBIOCALCANEAL ARTHRODESIS USING SHORT VERSUS LONG TIBIOCALCANEAL INTRAMEDULLARY NAILS. Timothy Noonan, MD, Avinash Patwardhan, PhD, Robert Havey, BS, Odysseus Paxinos, MD, and Michael Pinzur, MD. Loyola University Medical Center, Chicago, IL.

Tibiocalcaneal arthrodesis using an intramedullary device has become a popular means of achieving ankle arthrodesis. Recently, authors have noted that many patients developed a symptomatic stress reaction near the proximal aspect of the nail. The objective of this study was first to perform a biomechanical study looking at the area of highest strain in the tibia after tibiocalcaneal arthrodesis using the standard intramedullary device and comparing this to a custom designed long intramedullary implant. This study used five matched pairs of cadaveric lower extremities with intramedullary tibiocalcaneal arthrodesis nails of two different lengths. Strain gauges were precisely placed on particular standardized regions of the tibia adjacent to the interlocking screw hole and nail tip to determine any focal area of increased strain during loading. The tibia was mounted vertically on the Instron machine and loaded to 500N in a manner that simulated a healed arthrodesis at toe-off. The strain created by instrumentati on using the arthrodesis nail was then compared to the intact tibia, as well as with the longer nail. A paired 2-sample t test was used to compare various test conditions as well as the 2 sizes of nails. Rosette gauges adjacent to the proximal interolocking screw holes demonstrated a statistically significant focal increase in strain after insertion and locking of the standard nail compared with the intact tibia. Both nails had a localized increase in strain at the level of the proximal screw after insertion of the locking bolts. However, the increase in strain was statistically greater with the short nail (329 microstrain), compared with the long nail (68 microstrain). Strip gauges did show a symmetrical increase in tensile strain proximal to the interlocking screws. This increase was statistically significant in all gauges proximal to the screw hole. The insertion of the long nail substantially decreased the tensile strain by 27.4% along the distal portion of the tibia. The short tibiocalcaneal arthrodesis nail has a focal area of high strain adjacent to the proximal interlocking screw, and a generalized increase in tensile strain along the posterior surface of the tibia with a flexion moment applied. This may be a potential source of the stress fractures occurring in clinical practice. Despite the fact that the long nail has a large area of load sharing, there is not a large localized transfer of strain at the proximal interlocking screws.

MAGNETIC RESONANCE IMAGING IS AN EFFECTIVE TOOL IN EVALUATION OF VASCULAR ANOMALIES. Selene G. Parekh, MD, MBA, Bulent Erol, MD, Guirguis B. Hanna, MD, Jesse A. McCarron, MD, Jim S. Meyer, MD, and John P. Dormans, MD. Division of Pediatric Orthopaedic Surgery and Department of Radiology. The Children's Hospital of Philadelphia, Philadelphia, PA.

The purpose of this study was to evaluate the effectiveness of magnetic resonance imaging (MRI) in assessing the extent and/or the nature of musculoskeletal vascular anomalies (VAs), and to detect its role in eliminating the need for incisional biopsy in the management of these anomalies. We retrospectively reviewed the records of 70 children with various musculoskeletal VAs (hemangiomas and vascular malformations) treated in our hospital from 1990 to 2000. These patients had deep VAs localized within the extremities or flank, had a reviewable, high-quality, gadoliniumenhanced MRI, and had follow-up of 12 months or more. All MRIs were reviewed by a single, experienced musculoskeletal radiologist. The average age of the 70 patients (35 female, 35 male) at the initial presentation was 62 months (range, 1 month-18 years). The average follow-up time was 4 years (range, 1-10 years). Eight (11.4%) and eleven (15.7%) patients had MRIs that were excluded, as the readings did not comment on the nature and extent, resp ectively, of the lesions. These MRIs were unable to define the extent and nature of the VA, due to limitations of the area imaged or incomplete imaging of the entire lesion. After accounting for these exclusions, 54 (87%) of the 62 patients had MRIs that gave detailed information about the nature of the VAs preoperatively, and 55 (95%) of the 59 patients had MRIs that gave accurate information on the extent of the lesions. Eleven of the patients were closely monitored and observed, without any surgical procedures. The other 59 patients underwent a variety of surgical procedures. The sensitivity and specificity of MRI in correctly identifying hemangiomas was 33% and 95%, respectively. For vascular malformations, sensitivity of MRI was 91%, and specificity was 57%. MRI is a noninvasive, effective tool in the evaluation of musculoskeletal vascular anomalies. A combination of clinical findings and a high-quality, gadolinium-enhanced MRI, interpreted by an experienced radiologist, can usually delineate VAs from ot her types of soft tissue lesions, eliminating the need for incisional biopsy in many patients. To our knowledge, there is no current literature reviewing the importance of MRIs in the evaluation of VAs in the pediatric population. This study shows that MRI is effective in assessing the extent and/or nature of Vas, and it may diminish the need for incisional biopsies in many patients.

A PERIOPERATIVE COMPARISON OF INTRAMEDULLARY FIXATION VERSUS SLIDING HIP SCREW FIXATION FOR PROXIMAL FEMUR FRACTURES. A. Patel, MD, A. Dubey, MD, J. Feliccia, MD, and V. Shur, MD. Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, NY

Previous reports have suggested that the use of a short intramedullary hip nail is associated with a longer operative time and increased risk of intraoperative femur shaft fracture than use of sliding hip screw fixation; however, whether these two techniques differ in operative outcomes has not been fully evaluated. This study was undertaken to compare perioperative outcomes in patients treated with an intramedullary hip nail versus the sliding hip screw. Data were reviewed from 68 patients (mean age, 83 years) who were treated for extracapsular hip fractures with either a short intramedullary hip nail (Gamma Nail, Howmedica USA) or a sliding hip screw (Omega Hip Screw, Howmedica USA) from May 2000 through December 2001. The intramedullary nail was 180 mm long with a range of angles including 125 degrees, 130 degrees, and 135 degrees. The 34-, 5-, and 6-hole variants of the sliding hip screw system with either a 125 degree, 130 degree, or 135 degree plate were used. Data were analyzed for potential difference s in operative time, transfusion requirements, hospital length of stay (LOS), and perioperative complications between the 2 groups. Thirty-four patients underwent treatment with a short intramedullary hip nail and 34 patients underwent fixation with the sliding hip screw. Among patients treated with intramedullary hip nail, the mean operative time was 44 [+ or -] 15 minutes, mean blood transfusion requirement was 1.2 [+ or -] 1.1 units, and mean LOS was 6.4 [+ or -] 0.7 days. In those patients who were treated with the sliding hip screw, mean operative time was 48 [+ or -] 21 minutes, mean blood transfusion requirement was 1.2 [+ or -] 1.1 units, and mean LOS was 7 [+ or -] 2 days. There were no perioperative fractures in either group, and no patients were taken back to operating room for excessive drainage. There was no difference between the two groups with respect to any of the variables analyzed. These data demonstrate no difference in operative times, blood transfusion requirements, hospital LOS, or peri operative complications in patients treated with an intramedullary hip nail versus the sliding hip screw.

POSTERIOR LUMBAR FUSION: A COMPARISON OF INTERTRANSVERSE PROCESS FUSION WITH AND WITHOUT CONCOMITANT INTERBODY FUSION. K. Rad Payman, MD, Ben Pradhan, MD, Jim Youseff, MD, and Jeffrey C. Wang, MD. University of California--Los Angeles Medical Center, Los Angeles, CA.

Single-level lumbar fusion from a posterior approach may involve an intertranverse process fusion, with the possible addition of interbody devices (PLIF). A comparison of the indications and results has not been reported. The intent of this study was to compare the results, complications, and fusion rates between two spinal fusion procedures: (1) posterior lumbar interbody fusion (PLIF) and (2) posterolateral intertransverse process fusion. Thirty-one patients treated with posterior lumbar interbody fusion using interbody allograft spacers with segmental pedicle screw fixation and 34 patients treated with posterolateral intertransverse process instrumented fusions were examined. Surgical, perioperative, and follow-up data were obtained directly from medical records. The findings compared included estimated blood loss, need for blood transfusion, number of units transfused, operative time, number of days in hospital, need for transitional-facility care, complications, need for further surgery, radiographic fus ion, and clinical results. There was no significant difference in blood loss, need for transfusion, amount of blood transfused, hospital stay, transitional facility care, and complication rates when comparing the two procedures for fusion (P < .01). Patients with posterior lumbar interbody fusion procedures had a higher percentage of radiographic fusion at 1 year (100%) vs the posterolateral fusion group (85%) (P < .01). Additionally, 85% of the posterolateral fusion group had good to excellent clinical outcome, in comparison with 97% of patients undergoing posterior lumbar interbody fusions. In comparing PLIF and posterolateral intertransverse process fusions, we found a significantly higher percentage of radiographic fusion and better clinical results in patient undergoing posterior lumbar interbody fusions.

IONTOPHORETIC ADMINISTRATION OF DEXAMETHASONE SODIUM PHOSPHATE FOR ACUTE EPICONDYLITIS: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY. Dennis Rodin, MD, Robert Nirschl, MD, and Derek H. Ochiai, MD. Arlington, VA.

This randomized, multicenter, double-blind, placebo-controlled study evaluated the safety and effectiveness of dermal iontophoretic administration of dexamethasone sodium phosphate, 0.4% injection, USP, versus a saline placebo in patients with acute lateral elbow epicondylitis. 199 patients with acute epiconylitis from 11 study centers across the United States were enrolled in the study. Each patient was given 40 mA-min of either active or placebo treatment on 6 occasions. Treatments were spaced 1 to 3 days apart, and all 6 iontophoresis treatments were completed within a 15-day (+ 2 days) period. The primary efficacy variables included investigator's global evaluation of improvement (-1 = worsened through 4 = no symptoms) and patient's pain evaluation at the end of treatment. (100-mm visual analog scale; 0 = no pain through 100 = most pain imaginable). Secondary evaluations included a composite score based on the results of the primary efficacy variables, patient's evaluation of symptoms (0 = none through 4 = very severe), investigator's evaluation of pain (0 = no pain through 100 = most pain imaginable), and investigator's evaluation of tenderness (0 = no tenderness through 4 = very severe tenderness). Efficacy was based on a comparison of baseline scores with the scores 2 days after the sixth treatment. Efficacy variables were evaluated using Mantel-Haenszel summary chi-square tests for dichotomous or ordered data, and a factorial analysis of variance for continuous data. Patients receiving dexamethasone had a 23 mm improvement in VAS compared with 14 mm for the placebo group (P=.012). Fifty-two percent of dexamethasone patients had a score of moderate or better on the investigator global improvement scores, versus 33% of the placebo patients (P=.013) The percentage of patients with a score of moderate or better on the patient global evaluation of improvement was 48% for the dexamethasone group versus 41% for the placebo group. (P = .477). Significantly more patients receiving dexamethasone had improvement in all 3 primary variables than patients receiving placebo (P = .039). There were significant improvements in investigators' pain VAS and percentage of patients with moderate or better improvement in investigators' tenderness scores in favor of dexamethasone (P = .019 and P = < .001, respectively) Patients who completed al 6 treatments in 10 days or less appeared to show better efficacy than patients who completed all treatments over a longer period of time. Iontophoresis treatment was well tolerated by the majority of the patients, and was effective in reducing symptoms of epicondylitis.

ARTHROSCOPIC DEBRIDEMENT FOR THE TREATMENT OF OSTEOARTHRITIS OF THE KNEE: 2- AND 5-YEAR RESULTS. Dennis Rodin, MD, and Robert Nirschl, MD, Arlington, VA.

The purpose of this study was to evaluate the effect that arthroscopic debridement in osteoarthritic knees has on patient satisfaction and function. Thirty-six patients (mean age, 64.8 years) were available for 2- and 5-year follow-up after undergoing knee arthroscopy to treat arthritic symptoms refractory to conservative treatment. Surgical treatment included debridement of meniscal lesions, stabilization of chondral defects, removal of impinging osteophytes, and notchplasty. Age, symptoms, pre-and postsurgical HSS scores, compartments involved, motion, impinging lesions, and level of satisfaction were evaluated. At 2 years, 32/36 patients were satisfied. Mean HSS scores improved from 29.2 to 48.0. All four early failures had tricompartment disease, mean preoperative HSS csores of 21.5, and preoperative flexion contractures of 15.6 degrees. At 5 years, 25/36 were satisfied, with good to excellent results. Mean HSS scores decreased slightly to 43.2. 3/36 had some deterioration and were rated fair, and 8/36 we re considered treatment failures, requiring further surgery. The 25/36 with satisfactory results bad a mean preoperative flexion contracture of 7.3 degrees and average HSS scores of 33.2, whereas the other 11/36 had mean contractures of 15.0 degrees and average HSS scores of 20.1. Poor results were associated with contractures greater than 10 degrees (P = .05) and lower preoperative HSS scores (P = .05). Arthroscopic debridement of osteoarthritic knees has a favorable outcome in selected patients. Those patients with preoperative flexion contractures < 10 degrees and preoperative HSS scores > 22 beneficially responded to this method of treatment.

CORACOCLAVICULAR LIGAMENT RECONSTRUCTION WITH A BIODEGRADABLE SCREW. T. Talbert, MD, D.P. Mukherjee, ScD, A.L. Ogden, BS, R.H. Mayeux, BS, J. Green, MD, K.K. Sadasivan, MD, and JA. Albright, MD. Louisiana State University Health Sciences Center, Shreveport, LA.

Displaced acromioclavicular (AC) separations (type III or worse) involve disruption of the acromioclavicular ligaments and the coracoclavicular (CC) ligament complex. One of the techniques to obtain a stable fixation of AC separations is to use a 6.4-mm diameter metal screw. Problems with this technique include the need for screw removal, screw pullout of the coracoid, screw failure, infection, and coracoid fracture. The purpose of this study was to compare mechanical properties of a simulated AC separation fixed by a 4.5-mm cannulated biodegradable poly-L-lactic acid (PLLA) screw and a stainless steel (SS) screw of the same size. Seven matched pairs of fresh frozen shoulders were used. Bone mineral density (BMD) values of the coracoid base prior to screw placement were obtained from dual-energy x-ray absorptiometry (DEXA) scans (Hologic QDR 2000). Shoulders were randomly selected and fixed with a 4.5-mm stainless steel screw while contralateral shoulders were fixed with 4.5-mm PLLA screws. The pullout streng th and elongation to failure were measured using an Instron Mechanical Tester Model 4202 (Canton, MA). The statistical analysis of the data did not show any significant differences between the two screw types. Both the 4.5-mm cannulated SS and PLLA screws had pullout strengths greater than the 500 N failure strength reported for intact coracoclavicular ligaments. The displacement values were well below the 8-mm value reported for successful coracoclavicular ligament reconstruction. We concluded that the 4.5-mm cannulated bioabsorbable PLLA screw would provide adequate strength for fixation of coracoclavicular complex reconstructions.

Section on Otolaryngology--Head and Neck Surgery

MANAGEMENT OF ISOLATED EXTRAPULMONARY TUBERCULOSIS DIAGNOSED IN PREGNANCY Perrin C. Clark, MD, Myron Yencha, MD, FACS, and A. Kristina E. Hart, MD. Department of Otolaryngology--Head and Neck Surgery, Naval Medical Center, Portsmouth, VA.

The worldwide incidence of tuberculosis (TB) is increasing, largely as a consequence of both the rising prevalence of human immunodeficiency virus (HIV) and the emergence of drug-resistant strains. The pulmonary system is typically the primary site of involvement by this infectious disease; however, extrapulmonary disease does occasionally occur. TB can involve the neck, although this is uncommon. The usual presentation is bilateral adenopathy from pulmonary dissemination. Tuberculous cervical adenitis in the absence of pulmonary findings is rare. A concurrent diagnosis of pregnancy complicates the treatment of the infected patient. We present a case of isolated, unilateral tuberculous cervical adenitis diagnosed in a pregnant patient, and discuss the multidisciplinary approach necessary for the appropriate management of this unique situation.

NEWBORN HEARING SCREENING: ISSUES AND ANSWERS. Robert L. Baldwin, MD, and Casey Arnold, MSCCCA, Birmingham, AL.

The most common birth defect in the United States is sensorineural hearing loss (SNL), or nerve deafness, which affects 1 in every 1000 live births. SNL in newborns is more common than all other birth disorders for which screening is mandatory (eg, PKU, sickle cell disease, hypothyroidism). Although the age of identification of severe to profound nerve deafness has fallen from 2 1/2 years of age to 19 months, and the age of lesser degrees of deafness to 13 months, these facts still speak to inordinate and harmful delays in diagnosis and appropriate intervention. These delays may cause irreparable harm to the development of hearing, speech/language, educational, vocational, and social skills. There remains a significant lack of public and professional awareness on this issue, which, in turn, contributes to the current lack of effective programs in many of our nation's hospitals. In this paper, we describe the development and implementation of voluntary universal newborn hearing screening program for the state of Alabama. In addition to describing the development and public policy in such a program, pertinent issues regarding newborn hearing screening are addressed (eg, value, accuracy, cost-effectiveness, data management and follow-up, and results). Upon completion of this educational presentation, one should understand many of the issues involved with UNHS, know a successful methodology for implementation of such a program, and be able to understand the importance of data management and tracking in the overall success of UNHS.

NASAL MUCOEPIDERMOID CARCINOMA. John David Rosdeutscher, MD. Department of Surgery, Meharry Medical College, Nashville, TN.

Mucoepidermoid carcinoma is typically a tumor of salivary gland origin. It is assumed to arise from minor salivary gland tissue when mucoepidermoid carcinoma occurs in the nasal cavity or paranasal sinuses. We know of only one reported case of nasal mucoepidermoid carcinoma presenting as a midline dorsal nasal mass and not involving the nasal cavity. This case is included with three other similar cases reviewed by the Armed Forces Institute of Pathology (AFIP). The previous reported case, along with two other of the AFIP cases, had previous rhinoplasty. The patient in the case that we report of mucoepidermoid carcinoma presenting as a dorsal midline nasal mass not involving the nasal cavity had no previous surgery, but had a history of remote untreated nasal fracture.