Consulting in occupational health nursing.
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Consultants↗
Biomedical subjects
D R Roy
Publications and source records attributed to D R Roy.
Consulting in occupational health nursing. An overview.
1. The term consultant is defined as anyone who provides professional advice or services, which may include internal and external consultants. Consulting is a challenging way to practice occupational health nursing. 2. The consulting process involves problem solving and the creation of change. This process may be illustrated by using the nursing process and the steps of assessment, analysis, planning, implementation, and evaluation. 3. Successful occupational health nursing consultants are excellent communicators, are willing to market themselves, love problem solving, and are self starters.
Consultants↗
Hyphenated history: the Hueter-Volkmann law.
The language that orthopedic surgeons speak is filled with eponyms. Perhaps more than any other medical specialty, we speak cryptically to one another using code words and secret language. Certain hyphenated eponyms are particularly interesting, because they pique one's curiosity as to how these persons came to be partners in orthopedic history. We will offer some bits of orthopedic hyphenated history, outlining the pertinent work of the respective authors as well as associated background information. This paper focuses on the Hueter-Volkmann law, an important orthopedic concept concerning bone growth. This law bears the names of the two men credited with enunciating and popularizing it, Carl Hueter and Richard von Volkmann.
Bone Development↗
Open fracture of the tibia in children.
The records of eighty-three children who had had an open fracture of the tibial metaphysis or diaphysis between January 1983 and July, 1993 were studied retrospectively. The average duration of follow-up was fourteen months (range, two to seventy-five months). There were twenty-four grade-I, forty grade-II, thirteen grade-IIIA, six grade-IIIB, and no grade-IIIC fractures, according to the classification scheme of Gustilo et al. Sixty patients (72 per cent) had sustained the fracture when they were struck by an automobile, and forty-eight patients (58 per cent) had other associated major injuries. All fractures were treated with irrigation and débridement, and antibiotics were administered parenterally for a minimum of forty-eight hours. Thirty-two patients were managed with immobilization in a cast only; forty, with transcutaneous fixation with an average of two Steinmann pins followed by immobilization in a cast; nine, with external fixation; one, with open reduction and internal fixation with two screws and two pins; and one, with delayed intramedullary nailing. Fifty-seven wounds were closed primarily (forty-four, over a Penrose drain, and thirteen, without a drain), ten were treated with delayed closure, four were allowed to heal by secondary intention, seven were covered with a soft-tissue flap, and five were treated with skin-grafting (a split-thickness skin graft was used for four, and a split-thickness and a full-thickness skin graft were used for one). The average time to union was fifteen weeks (range, five to sixty-one weeks), with the fracture healing by sixteen weeks in sixty-four patients (77 per cent). Eighteen patients (22 per cent) had delayed union, and only one patient (1 per cent) had non-union. Secondary procedures were necessary to achieve union in only two patients. Two patients had a superficial wound infection, and no patient had osteomyelitis. One patient, who had been managed with external fixation, had a pin-track infection; none of the patients who had had transcutaneous fixation had a pin-track infection. Two patients had a compartment syndrome, and two patients had a transient stretch injury of a nerve (the peroneal nerve in one and the sciatic nerve in the other). Four fractures healed with an angulatory deformity of more than 10 degrees in any plane. Five patients had overgrowth of the limb of one centimeter or more. Physeal arrest did not occur in any patient. We concluded that treatment of unstable open fractures of the tibia in children with débridement and transcutaneous fixation followed by immobilization in a cast leads to good anatomical and functional results. We prefer this technique to external fixation, which is associated with several potential complications. Loose closure of a clean open wound over a Penrose drain is effective and can be safely utilized in selected children.
Adolescent↗
Operative treatment of supracondylar fractures of the humerus in children: the Cincinnati experience.
A retrospective review of 115 patients treated surgically for displaced supracondylar humeral fractures was conducted. All patients had a minimum of 2 years' follow-up (range 2 to 7 years). According to a modified Gartland (19) classification system, 18.3% were type II (21/115), 77.4% were type III (89/115), and 4.3% (5/115) type IV supracondylar fractures. Twelve percent (14/115) of patients presented with neurapraxias, with the radial nerve being the most commonly affected. Sixty percent (69/115) of patients were treated with a crossed K-wire configuration, while another 30% (35/115) received two lateral pins as their internal fixation. The remaining 10% (11/115) of patients were treated with a variety of "other" pin configurations, including four lateral pins, three lateral pins, one lateral and one medial pin constructs. Eighty patients were treated in the lateral position with the C-arm horizontal, while 35 were treated supine using the C-arm base as the operating table. There were 23 complications noted, with 5 children with cubitus varus, 4 children with cubitus valgus, 3 pin-tract infections requiring antibiotic therapy, 3 failed closed reductions in the operating room that required formal open reduction and internal fixation, and 2 patients experiencing pin breakage. For a subgroup of 77 patients, satisfactory clinical and radiographic data were available for the purpose of evaluating these patients with Flynn's supracondylar rating scale as well as Baumann's angle (15). Eighty-three percent had good or excellent results, 14- had fair results, and 3% had poor results. At completion of bony healing 9 children fell outside the normal range for Baumann's angle established by Williamson et al. (45). Five children were noted to have cubitus varus (Baumann's angles ranging from 83 degrees to 90 degrees) and 4 children had significant cubitus valgus (Baumann's angles ranging from 60 degrees to 63 degrees).
Bone Nails↗
Femoral lengthening in patients having abnormal ipsilateral hip or knee.
Femoral lengthening using the Wagner technique was performed for 13 patients with abnormal adjacent joints. An average of 6.3 cm (19.5%) of lengthening was achieved. Three patients had no difficulties during lengthening. Transient non-surgical problems identified were blood pressure elevation, nerve palsy, and psychiatric reactions. Significant obstructions or complications occurred 13 times in nine cases. These included contractures of ipsilateral joints, angulations of the lengthened femur, Wagner device slippage, nonunion, and late hip subluxation. Other authors have reported similar difficulties in patients with normal ipsilateral joints. In this series, the advantage of achieving greater length appeared to outweigh the complications.
Adolescent↗
Dysplasia epiphysealis hemimelica. Upper limb involvement with associated osteochondroma.
Dysplasia epiphysealis hemimelica is a rare developmental disorder characterized by an osteocartilaginous outgrowth arising from 1 or more epiphyses. This condition is generally confined to the lower limb and usually involves either the medial or lateral side of an epiphysis. Reported here is an atypical case that involved the upper extremity and was associated with a typical metaphyseal osteochondroma in the same limb. The occurrence of histologically identical lesions at 2 different sites suggests that the lesions were different modes of expression of the same pathologic process.
Arm↗
Developmental dysplasia of the hip.
OBJECTIVE: The definition and early treatment of congenital dysplasia of the hip are controversial. The purpose of this study was to discuss the reasons for changing the acronym to developmental dysplasia of the hip (DDH) and to address its early detection and treatment. DESIGN: This multicenter study was designed to provide an updated assessment of the definition, pathologic anatomy, prevalence, etiology, natural history, early detection, and treatment of DDH. RESULTS: DDH more accurately describes the condition previously termed congenital dysplasia of the hip. The disorder is not always present at birth (congenital) and an infant may have a normal neonatal hip screening examination and subsequently develop a dysplastic or dislocated hip. Developmental dysplasia encompasses the wide spectrum of hip problems seen in infants and children. Physicians should understand that a normal neonatal screening examination does not assure normal hip development. The diagnosis of developmental dysplasia is made by physical examination. The Ortolani and Barlow maneuvers were designed to detect a subluxatable, dislocatable, or dislocated hip in the neonatal period. In the older child, limited abduction becomes a more reliable sign. The examination is variable depending on the type of dysplasia and changes with growth. The ultrasound is proving to be a sensitive tool in confirming the diagnosis in newborns and infants from birth to 4 months of age. The ultrasound is also valuable in older infants in terms of documenting that the dysplasia is responding to treatment. However, the ultrasound depends on an experienced sonographer and, in some cases, may be too sensitive, resulting in overtreatment. After 3 to 4 months of age, an anteroposterior pelvis radiograph can confirm the diagnosis. CONCLUSIONS: All newborns should have a neonatal hip screening physical examination. After screening, the hips should be re-examined during health examination visits at 2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year of age. If any question arises during these visits or if there are associated risk factors, we recommend an ultrasound if the infant is < 4 months of age or an anteroposterior pelvis radiograph if > 4 months of age.
Follow-Up Studies↗
Digital schwannoma in a skeletally immature child.
Soft tissue neoplasms of the hand are rare in general and even more uncommon in children. The most commonly considered diagnoses include ganglion, inclusion cyst, lipoma, subcutaneous foreign body granuloma, and tendon sheath xanthoma. Aside from pressure sensitivity, masses on the palmar aspect of the hand are often asymptomatic. The case reported here identifies a primary neural neoplasm (neurilemmoma) that involves a small peripheral nerve in the hand of a twelve-year-old child. The patient had no neurologic symptoms and illustrates the need to include neurilemmomas in the differential diagnosis of hand masses in children.
Child↗
Perthes'-like changes caused by acquired hypothyroidism.
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Child, Preschool↗
Synthesis and characterization of extended and deleted recombinant analogues of parathyroid hormone-(1-84): correlation of peptide structure with function.
Recombinant analogues of human parathyroid hormone [hPTH-(1-84)] were expressed in Escherichia coli harboring plasmids containing synthetic genes under the control of the lac promoter. The level of expression of the gene encoding the truncated analogue, hPTH-(3-84), was greater than that of the gene encoding full-length hPTH-(1-84) but less than that of the gene encoding proparathyroid hormone (hProPTH). This may be due in part to the relative efficiency of translation of the mRNA as suggested by secondary structure analysis and in part because of enhanced stability of the extended peptide. Formylmethionyl derivatives of hProPTH and of hPTH-(3-84) and underivatized hPTH-(3-84) were purified by HPLC, and their identity was confirmed by NH2-terminal sequencing and amino acid analysis. The bioactivity of these recombinant peptides was then tested in skeletal and renal adenylate cyclase assays in vitro and in assays examining effects on plasma and urine calcium and phosphate levels and on urine cyclic AMP levels in vivo. The NH2-terminally extended analogue fMet-hProPTH displayed 10% of the in vitro activity of hPTH-(1-84) and was a partial agonist in vivo. The peptides hPTH-(3-84) and fMet-hPTH-(3-84) were inert in vitro and were very weak in vitro antagonists when compared to the NH2-terminal analogue bovine [Nle8,18Tyr34]PTH-(3-34)-NH2. In vivo, hPTH-(3-84) and the bPTH-(3-34) analogue, when assayed at a 10:1 molar ratio relative to bPTH-(1-84), were each inert, and neither demonstrated antagonist activity at these concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Operative management of fractures of the shaft of the radius and ulna.
Diaphyseal fractures of the radius and ulna usually can be managed by closed reduction and immobilization in a long arm cast. Open fractures may benefit from pinning if the reduction will be difficult to maintain. Fractures that cannot be reduced or for which satisfactory alignment maintained are best managed operatively. Our preference is for intramedullary fixation. Operative management will be necessary most frequently in children older than age 10.
Adolescent↗
Subtalar stabilization of the planovalgus foot by staple arthroereisis in young children who have neuromuscular problems.
A new approach was developed for the treatment of planovalgus feet in children who have spastic cerebral palsy and are less than six years old. The procedure consists of subtalar stabilization (arthroereisis) with a Vitallium staple, and it corrects alignment, restores balance, and allows continued function. It is safe, technically simple, and efficient. Between 1980 and 1988, forty-eight arthroereises were done. The results of thirty-one procedures in twenty patients who were two to ten years and ten months old at the time of the operation were followed for an average of 4.1 years (range, two to seven years). Approximately 85 per cent of the results were excellent or good. Only one foot needed a revision; this was due to migration of the staple. At the most recent follow-up, the talocalcaneal angle had not changed in about 50 per cent of the feet. In another seven, the change ranged from 5 to 10 degrees. All of these patients had a satisfactory result. In all but three feet, the goal of maintaining the stability of the talocalcaneal joint without orthotics or osseous fusion was achieved. Originally, the procedure was done only in patients who were less than six years old, but, because of its success, the indications were extended to children of any age who had severely involved and neurologically compromised feet. Satisfactory results were obtained in the older children as well.
Cerebral Palsy↗
Completely displaced distal radius fractures with intact ulnas in children.
Completely displaced distal radius fractures with intact ulnas are uncommon, difficult-to-reduce fractures in children. Ten of these fractures were retrospectively reviewed from a series of more than 600 forearm fractures. Eight of ten patients were available for follow up clinically and radiologically at an average of 21 months. Considerable remodeling was noted including two fractures that were left in an overriding position of 10 mm. If angulation does not exceed 16 degrees of radial deviation and 20 degrees of dorsal angulation, repeat manipulations need not be performed. Stimulation of growth by the fracture restored radial length. Thus, reduction of the overriding is unnecessary.
Adolescent↗
Influence of the amino-terminus on in vitro and in vivo biological activity of synthetic parathyroid hormone-like peptides of malignancy.
We compared the bioactivities of a synthetic truncated NH2-terminal fragment of the human (h) PTH-like peptide (PLP) associated with malignancies [hPLP-(3-34)], an intact NH2-terminal fragment [hPLP-(1-34)], and an NH2-terminal fragment of PTH [hPTH-(1-34)]. Although hPLP-(1-34) was less potent than hPTH-(1-34) in stimulating adenylate cyclase in rat renal membranes, hPLP-(1-34) and hPTH-(1-34) were equipotent in stimulating adenylate cyclase in OK renal cells as well as in UMR 108 osteosarcoma cells in vitro. In osteosarcoma cells, each of these peptides could desensitize adenylate cyclase responses to itself and to the other peptide, but could not reduce stimulation by prostaglandin E2. Renal membranes of vitamin D-deficient rats with secondary hyperparathyroidism had a reduced PLP-stimulated as well as PTH-stimulated adenylate cyclase response. The truncated analog hPLP-(3-34) was only a weak partial agonist and an antagonist in vitro, produced equivalent inhibition of hPLP-(1-34) and hPTH-(1-34) in renal and osseous cells, and could not desensitize agonist responses. In thyroparathyroidectomized rats in vivo, hPLP-(1-34) and hPTH-(1-34) increased cAMP excretion, enhanced phosphaturia, maintained plasma calcium, and reduced calciuria. Equimolar concentrations of hPLP-(3-34) produced no increases above control levels; however, high concentrations of this peptide mimicked PTH actions on renal and plasma ion handling while modestly augmenting cAMP excretion. These results demonstrate the importance of the first two residues of PLP for bioactivity, indicate that PLP and PTH interact at common receptor sites in vivo as well as in vitro, suggest that PLP may not be less potent than PTH in renal target cells, and indicate that the net result of interaction of these peptides with their common receptor in target tissues may reflect both activation and desensitization of receptor-mediated events.
Adenylyl Cyclases↗
Magnesium reabsorption in the juxtamedullary loop of Henle: effect of magnesium deprivation.
To determine the contribution of the juxtamedullary loop of Henle to magnesium reabsorption during magnesium deficiency, we performed two-phase micropuncture studies of end-descending limbs in a group of magnesium-deficient rats (n = 7) and in a pair-fed control group (n = 8) given MgCl2 in their drinking water. In the magnesium-deficient rats, daily excretion of magnesium fell to very low values (1.2 +/- 0.2 vs. 52 +/- 12 microM.day-1.100 g body weight-1, p less than 0.05). Plasma magnesium concentration and fractional magnesium excretion during the control phase were nearly 52 and 27%, respectively, of the values observed in pair-fed controls. Fractional magnesium delivery to the end-descending limb did not differ significantly between the two groups. During the acute magnesium repletion phase, fractional magnesium excretion and fractional magnesium delivery to the end-descending limb increased by a similar value in the two groups of rats, despite a lower filtered load of magnesium in the magnesium-deficient group. Absolute magnesium reabsorption upstream to the end-descending limb was lower in the magnesium-deficient rats but was otherwise tightly coupled to the filtered load of magnesium (Y = 0.91 + 0.37 x, r = 0.82, p less than 0.05). Similar observations were made with regards to whole kidney magnesium reabsorption. Our results suggest that, in young magnesium-deficient rats, magnesium reabsorption is tightly coupled to the filtered load of magnesium both in segments upstream to the juxtamedullary end-descending limb and in the whole kidney, and that a reabsorptive defect for magnesium is not evident in this setting.
Animals↗
Dyazide-induced reversible acute renal failure associated with intracellular crystal deposition.
Acute interstitial nephritis due to Dyazide therapy, ie, a combination of hydrochlorothiazide (25 mg) and triamterene (50 mg), has been recently reported in the literature. This had been characterized by nonoliguric renal failure after a long latent period (weeks) following exposure to the drug. Pathologic data have indicated a drug-induced hypersensitivity reaction. We report here one case of oliguric acute renal failure after a massive Dyazide intoxication. Based on the results of the renal biopsy and clinical course, we propose that the oliguria was secondary to a direct toxic effect on the tubules, and intrarenal obstruction was secondary to triamterene crystals and crystal-laden cells. In addition, pathologic findings also suggested a moderate hypersensitivity reaction. After hemodialysis and short-term steroid therapy, the patient achieved complete recovery of renal function within 12 days. Recent knowledge of triamterene-induced nephrolithiasis helps to explain the pathogenesis of acute renal failure in this patient, and is briefly reviewed here.
Acute Kidney Injury↗