Showing papers by "Rush University Medical Center published in 1988"

Differences between sub-populations of cultured bovine articular chondrocytes. I. Morphology and cartilage matrix production

Abstract: Bovine articular chondrocytes cultured in agarose gel comprise a heterogeneous population when judged by morphological and histochemical criteria. The purpose of the present experiments was to compare, under the same conditions of culture, sub-populations of chondrocytes derived from different depths of articular cartilage. Sub-populations of chondrocytes were cultured separately following their isolation from slices of articular cartilage cut from successive depths of the tissue. Chondrocytes derived from superficial and deep zones differed significantly in morphology, rate of proliferation, and activity in secreting a proteoglycan-rich extracellular matrix. The differences are sufficient to account for the heterogeneity observed in cultures of the entire cell population, and the correlate well with known variations with depth in morphology and histochemistry of intact articular cartilage. These results demonstrate that articular chondrocytes continue in culture to express metabolic differences which reflect their original anatomical location; such differences may have important functional significance.

Differences between sub-populations of cultured bovine articular chondrocytes. II. Proteoglycan metabolism.

Abstract: Sub-populations of bovine articular chondrocytes derived from different depths of the cartilage showed differences in accumulation of proteoglycan-rich extracellular matrix in culture. To extend these morphological studies, the synthesis and catabolism of 35S-labeled proteoglycans have been examined in similar cultures. Chondrocytes from deep zones synthesized significantly more proteoglycans than cells from the superficial zone. While all populations of chondrocytes synthesized pre-dominantly aggregating proteoglycans, a higher proportion of isotope was present in non-aggregating proteoglycans in cultures of superficial chondrocytes, by comparison with those of deep cells. Proteoglycans were degraded more rapidly by superficial cells than by chondrocytes from deeper layers. These results correlate both with previous histochemical studies of similar cultures, and with known depth-related variations in biochemical composition of intact articular cartilage.

Vicissitudes of depressed mood during four years of medical school.

Abstract: We describe the vicissitudes of depressed mood for one medical school class that was assessed repeatedly overtime, from the first day of medical school until several months short of graduation, using the Beck Depression Inventory (BDI). Using an arbitrarily defined BDI cutoff point of 14 or greater, at least 12% of the class showed considerable depressive symptoms at any assessment during the first three years; the largest fraction (25%) was symptomatic near the end of the second year. The median class BDI score increased almost threefold during the first two years. Students were likely to be in a similar class ranking at all assessments, indicating that for many students dysphoric mood was enduring. Those with BDI scores of 21 or greater were more likely to quit medical school. Students with high scores for dysphoria were not more likely to evidence a family history of major depression or concomitant substance abuse. Women medical students were not more vulnerable to depressed mood than men.

The Importance of Sample Size in the Interpretation of the Renal Biopsy

Abstract: The number of abnormal glomeruli present in a renal biopsy can be viewed as a binomial distribution. Recognition of this fact permits a quantitative assessment of the effect of biopsy sample size in renal biopsy interpretation. If the percent of glomerular involvement in a biopsy is used to determine the severity of a focal glomerular lesion, a small biopsy sample size will lead to considerable misclassification of disease severity. In addition, a small biopsy sample size will make the exclusion of focal disease difficult.

Calcium phosphate-coated porous titanium implants for enhanced skeletal fixation.

Abstract: Porous titanium fiber implants for cementless skeletal fixation by bone ingrowth were treated with a calcium phosphate coating applied by a plasma flame-spray technique. In a paired experiment, treated and control implants were inserted in the humeri and olecranons of 36 adult dogs for periods of 1, 2, 4, and 6 weeks. After the animals were sacrificed, a biomechanical evaluation of the strength of skeletal fixation of the implants and a histologic evaluation of bone ingrowth was done. The mean shear strength of skeletal fixation at four weeks for the calcium phosphate-coated implants was 24% greater (P less than .01) than for paired controls. No difference in strength of fixation between treated and control implants was present at other time periods. The osteoconductive properties of the ceramic coating were demonstrated by bone forming in direct contact with the calcium phosphate coating on the metal fibers of the treated implants. No significant increase for the volume of bone ingrowth was established for treated implants compared to paired controls at any time period.

Inadvertent Subdural Injection: A Complication of an Epidural Block

Abstract: Twenty-one hundred eighty two consecutive lumbar epidural injections were studied to determine the incidence of inadvertent subdural block retrospectively. A subdural block is defined as an extensive neural block in the absence of subarachnoid puncture, that is out of proportion to the amount of local anesthetic injected. Subdural injection is a complication of epidural block that probably occurs more frequently than previously recognized. An earlier report has estimated the incidence of subdural block to be 0.1%. This study, however, reports an incidence of 0.82% from a sample size of 2182 patients. Cadaveric dissection was also performed, further clarifying the presence and anatomic position of the subdural space.

Retention of the posterior cruciate in total knee arthroplasty

Abstract: Retention of the posterior cruciate ligament in total knee arthroplasty is discussed in biomechanical and clinical terms and the implications for design, kinematics, function, and prosthesis longevity considered. The specific roles of passive range of motion, femoral rollback, stresses on the implant-bone-prosthesis cement system, and wear are examined. The authors argue that the posterior cruciate ligament improves passive range of motion, the mechanical efficiency of the knee musculature and thus improved stairclimbing efficiency, reduces stress at the cement-bone-implant interfaces, and has little or no impact on the polyethylene wear problems.

Effects of extracellular calcium on calcium movements of excitation-contraction coupling in frog skeletal muscle fibres.

Abstract: 1. The effect of low extracellular free calcium ion concentration ([Ca2+]o) on the transient changes in cytoplasmic [Ca2+] associated with membrane depolarization (Ca2+ transients) was studied on single cut skeletal muscle fibres of the frog, voltage clamped in a double-Vaseline-gap chamber. The Ca2+ transients were monitored with the dye Antipyrylazo III diffused intracellularly. 2. The Ca2+ transients were substantially reduced in external salines with low [Ca2+] (10(-5) M or less and Mg2+ substituted for Ca2+). This decrease was more noticeable at late times during 100 ms or longer depolarizing pulses. 3. The rates of the processes that remove Ca2+ from the myoplasmic solution were not altered by the low [Ca2+]o. This implies that the input flux of Ca2+ into the myoplasm was reduced. 4. The Ca2+ input flux, equal to release flux from the sarcoplasmic reticulum (SR) plus Ca2+ influx via the T-tubule membrane Ca2+ channel, was derived from the Ca2+ transient. In low [Ca2+]o the peak input flux was reduced by 45% (n = 16 fibres) and decayed more rapidly during a depolarizing pulse. 5. The reduction in Ca2+ influx via the T-tubule membrane Ca2+ channel due to the reduced [Ca2+]o could not account for more than 5% of the reduction in Ca2- input flux, which was thus interpreted as an actual reduction of release from the SR. 6. The inward (T-tubular) Ca2+ current was not associated with this effect of extracellular Ca2+ as the effect was voltage independent at high intracellular voltages at which the Ca2+ inward current was strongly voltage dependent. 7. Low [Ca2+]o made Ca2+ release more readily inactivatable; the effect of low [Ca2-]o is best described as a left shift by 29 mV of the 'inactivation curve' of Ca2+ release, relating peak release flux to membrane holding potential. 8. The reduction of Ca2+ release by low [Ca2+]o was not accompanied by changes in the voltage dependence of Ca2+ release or in the threshold voltage for just-detectable release. 9. The results are consistent with a primary effect of Ca2+ on the T-tubular-membrane voltage sensor of excitation-contraction coupling.

Neutron vs photon irradiation of inoperable salivary gland tumors: Results of an RTOG-MRC cooperative randomized study

Abstract: A total of 32 patients with inoperable, recurrent or unresectable malignant salivary gland tumors were entered on a randomized RTOG/MRC study comparing fast neutron radiotherapy with conventional photon radiotherapy. Twenty-five patients were entered from the United States and 7 patients were entered from Scotland. Seventeen patients were randomized to receive neutrons and 15 patients were randomized to receive photons. Sixty-one percent of the neutron-treated patients and 75% of the photon-treated patients presented with inoperable or unresectable tumors, while 39% of the neutron-treated and 25% of the photon-treated patients had recurrent disease. Twenty-five patients were study-eligible and analyzable. The minimum follow-up time is 2 years. The complete tumor clearance rates at the primary site were 85% (11/13) for neutrons and 33% (4/12) for photons following protocol treatment (p = 0.01). The complete tumor clearance rates in the cervical lymph nodes were 86% (6/7) for neutrons and 25% (1/4) for photons. The overall loco/regional complete tumor response rates were 85% and 33% for neutrons and photons respectively. The loco/regional control rates at 2 years for the 2 groups are 67% for neutrons and 17% for photons (p less than 0.005). The 2-year survival rates are 62% and 25% for neutrons and photons respectively (p = 0.10). These findings are consistent with previously published uncontrolled series.

Voltage sensors of the frog skeletal muscle membrane require calcium to function in excitation‐contraction coupling.

Abstract: 1. Intramembrane charge movements and changes in intracellular Ca2+ concentration (Ca2+ transients) elicited by pulse depolarization were measured in frog fast twitch cut muscle fibres under voltage clamp. 2. Extracellular solutions with very low [Ca2+] and 2 mM-Mg2+ , shown in the previous paper to reduce Ca2+ release from the sarcoplasmic reticulum (SR), were found to cause two changes in charge movement: (a) a decrease (-12 nC/microF) in the charge that moves during depolarizing pulses from -90 to 0 mV, termed here 'charge 1'; (b) an increase (+7 nC/microF) in the charge moved by hyperpolarizing pulses from -90 to -180 mV, termed 'charge 2'. 3. The increase in charge moved by hyperpolarizing pulses was correlated (r = 0.64) with the decrease in charge moved by depolarizing pulses and both were correlated with the inhibition of Ca2+ release recorded in the same fibres. 4. The low Ca2+ solutions caused a shift to more negative voltages of the dependence relating charge movement and holding potential (VH). This shift is of similar magnitude (about 22 mV) and direction as the shift in the curve relating Ca2+ release flux to VH (previous paper). 5. In solutions with normal [Ca2+] a conditioning depolarization to 0 mV, of 2 s duration, placed 100 ms before a test pulse from -70 to 0 mV, reduced by 30% the amount of charge displaced by the test pulse. Conditioning pulses of 1 s or less caused potentiation of charge movement by up to 30%. 6. In low Ca2+ solutions, reduction of charge was observed at all durations of the conditioning pulse. The duration for half-inhibition was near 200 ms. 7. An extracellular solution with no metal cations caused a more radical inhibition than the low Ca2+ solutions that contained Mg2+. The inhibition of Ca2+ release was essentially complete (90-100%). The charge moved by a pulse to 0 mV was reduced by 20 nC/microF and the charge moved by a pulse to -170 mV increased 8 nC/microF. This shows that Mg2+ supports excitation-contraction (E-C) coupling to some extent. 8. A state model of the voltage sensor of E-C coupling explains qualitatively the observations in both papers.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of continuous epidural infusion of fentanyl-bupivacaine and morphine-bupivacaine in management of postoperative pain.

Abstract: The short duration of epidural fentanyl has limited its direct comparison with epidural morphine in previous reports. The following study was performed of continuous postoperative epidural infusions at 5 ml/hr fentanyl 10 micrograms/ml (n = 59) or morphine 0.1 mg/ml (n = 48), both with bupivacaine 0.1%, in patients having cesarean sections. Postoperative evaluations included the frequency and magnitude of clinically evident respiratory depression, the adequacy of analgesia, nausea, pruritus, the ability to ambulate, and other side effects for 24 hours. Analgesia and the number of supplemental narcotic injections needed were similar in both groups. The incidence of nausea and pruritus was significantly less in the patients receiving fentanyl. No patient developed respiratory depression in either group. Patient and staff acceptance of the continuous epidural technique was excellent because there were only minor catheter-related problems associated with its use. It is concluded that continuous epidural fentanyl combined with bupivacaine offers excellent postoperative analgesia with minimal side effects.

Diseases of the adrenal cortex

Abstract: The adrenal cortex is functionally a three-dimensional gland that secretes glucocorticoids, mineralocorticoids, and sex steroids. Of these three classes of steroids only the gluco- and mineralocorticoid hormones are necessary to sustain life. The availability of sensitive and specific radioimmunoassays has permitted accurate measurement of practically every steroid hormone secreted by the adrenal cortex. As in other endocrinopathies, suppression studies are employed when hyperfunction is suspected, while provocative tests are used to detect hypofunction. These dynamic studies enable the clinician to evaluate the functional status of the adrenal cortex. The anatomic configuration of the adrenal cortices is delineated by high-resolution computed tomography (and magnetic resonance imaging), obviating the need for invasive procedures such as venography or arteriography. The disorders of the adrenal cortex can be viewed from the dual perspectives of hyperfunction and hypofunction. Clinical expressions of hyperfunctional adrenocortical syndromes include Cushing's syndrome, primary hyperaldosteronism, and the adrenogenital syndrome. The expressions of hypofunctional syndromes include Addison's disease and selective hypoaldosteronism. The diagnosis and treatment of these disorders are outlined in this issue.

Uterine leiomyomas in the infertile patient: preoperative localization with MR imaging versus US and hysterosalpingography

Abstract: Eleven women with a history of infertility and uterine leiomyomas underwent magnetic resonance (MR) imaging of the pelvis prior to myomectomy Nine also underwent preoperative pelvic ultrasonography (US), and ten underwent hysterosalpingography All studies were interpreted prospectively by independent observers With each imaging modality, the location (one of 11 anatomic segments), size, and appearance of detected uterine leiomyomas were determined and compared with surgical and histologic findings Among the nine patients who underwent both MR and US, the sensitivity (85%) and accuracy (94%) of MR imaging for abnormal segments was significantly better than that of US (sensitivity = 69%, P = 015; accuracy = 87%, P = 043) For the ten patients who underwent both MR and hysterosalpingography, the sensitivity (91%) and accuracy (96%) of MR imaging was better than that of hysterosalpingography (sensitivity = 18%, P = 0005; accuracy = 72%, P = 0005) The specificities of the three modalities did not significantly differ (100%, 97%, and 98% for MR, US, and hysterosalpingography, respectively) These data suggest that MR imaging is superior to US or hysterosalpingography for preoperatively locating uterine leiomyomas

Influence of dynamic factors on the lumbar spine moment in lifting.

Abstract: Flexion-extension moments occurring at the L5-S1 level of the spine were calculated when subjects lifted a 150N box at slow, normal and fast speeds. Three methods of lifting were used: leg-lifting, back-lifting and free-style lifting. The peak moment increased linearly with increasing lifting speed. The increase was greatest for back lifts, but occurred with the other two lifting techniques as well. Inertial forces should be considered when analysing lifting tasks biomechanically. Excessive speed of lifting, including jerking, should be avoided.

Practice improves even the simplest movements

Abstract: Three subjects practiced accurate, fast elbow flexions of 54° to a 3° wide target. Movements of 36°, 54° and 72° were then tested. Comparison over the three distances showed that the normally monotonic relationship between movement distance and movement time is alterable by specific training. Subjects learn to go faster over the practiced distance by refining their neural commands to the muscles. The benefits of practice only partially transfer to other distances. We conclude that many of the relationships seen among movement variables in simple tasks are plastic in nature and affected by prior experience.

Prognostic Significance of DNA Aneuploidy in Stage I Cutaneous Melanoma

Abstract: The prognostic significance of DNA aneuploidy was studied restrospectively in 177 Stage I cutaneous melanomas. DNA content was determined by flow cytometry of propidium iodide-stained nuclei recovered from formalin-fixed, paraffin-embedded material. Of 162 evaluable histograms, 124 were diploid, 35 aneuploid, and 3 tetraploid. Aneuploidy strongly correlated with established predictors of unfavorable prognosis, namely, thickness p less than .005, level p less than 0.005, ulceration p less than 0.005, and presence of vertical growth phase p less than 0.02. Overall, aneuploidy was strongly correlated with recurrence (p less than 0.005) and shorter disease-free survival (p less than 0.0001). Aneuploidy was an independent predictor of recurrence for tumors less than 1.5 mm thick (p less than 0.0001) and greater than or equal to 3 mm thick (p = 0.031). For melanomas 1.5-2.9 mm thick, aneuploid tumors had a 27% higher recurrence rate than diploid tumors (63% vs. 36%). This was not statistically significant (p = 0.247). In a multivariate analysis of common predictors stratified by thickness, DNA aneuploidy was the most significant independent parameter (p less than 0.002). DNA content appears to be an important stratification parameter for Stage I cutaneous melanoma.

Accuracy constraints upon rapid elbow movements

Abstract: Kinematic and myoelectric variables associated with rapid elbow-flexion movements of various distances to targets of various widths were studied. The movement time in these experiments conformed to Fitts’ law: movement time increased with target distance and decreased with target width. Peak movement velocity, electromyograph (EMG) duration, and EMG quantity were poorly described by Fitts’ law, for increases in target width were accompanied by increases in these variables. We show with regression equations, using separate weighting coefficients, that kinematic and myoelectric variables can be related to distance and target width. The use of distance and target width as independent variables allows us to suggest that the literature does not agree on the relation between EMG and distance moved partly because of the influences of the target on this relationship. We propose that human voluntary movement involves a subject “strategy,” or set of internal constraints, that affect movement outcome. Significant el...

The automatic implantable cardioverter-defibrillator. Clinical experience, complications, and follow-up in 25 patients.

Abstract: • Twenty-five patients with recurrent ventricular tachyarrhythmias underwent implantation of an automatic implantable cardioverter-defibrillator. The mean length of follow-up was 11.9±10.8 months. Before the implantation, the patients had survived one or more cardiac arrests (mean, 1.7; range, 1 to 4) and episodes of syncope (mean, 2.2; range, 2 to 3) and had received 6.0±1.0 antiarrhythmic drug trials. The in-hospital complications included death (two patients), reoperation (one patient), intraoperative myocardial infarction (one patient), sensing-failure (one patient), infection (five patients), and pocket seroma (two patients). The posthospital complications included device failure (four patients), device deactivation (one patient), and inappropriate discharge (two patients). The device discharged appropriately in seven patients due to sustained ventricular tachycardia. During electrophysiologic measurements, the energy requirement for successful cardioversion-defibrillation was related to the type of ventricular arrhythmia induced (monomorphic or pleomorphic ventricular tachycardia or fibrillation). Ventricular tachycardia acceleration occurred in ten patients (40%). No significant changes were found in the size of the electrograms or in the cardioversion threshold during early and late follow-up measurements. Life table analysis showed a 12-month survival rate of 86% and an arrhythmic death survival rate of 100%. We confirm the improved rate of survival in this high-risk group of patients, despite significant complications. (Arch Intern Med1988;142:70-76)

CNS complications of AIDS: CT and MR findings.

Abstract: AIDS is now a common disease, seen daily in large metropolitan medical centers. Neuroimaging techniques such as CT and MR are critical to the detection and diagnosis of CNS complications. Intracerebral infections are common. These infections frequently are caused by opportunistic organisms; less commonly, they are bacterial infections. The cranial imaging features on CT and MR are not pathognomonic, but their distribution or appearance (e.g., asymmetric target lesions of toxoplasmosis) may have predictive value in a known AIDS patient. The superior contrast resolution of MR makes it a more sensitive cross-sectional imaging tool for evaluating intracerebral abnormalities associated with a variety of infectious processes. Differential diagnoses still include metastatic disease, lymphoma, and infarcts. When MR is used as the initial cross-sectional imaging study, contrast-enhanced CT may still be necessary to further characterize a lesion. Currently, more experience exists with CT for follow-up of the AIDS patient with CNS manifestations. MR, particularly with gadolinium-DTPA as a contrast medium, will probably become the imaging method of choice.

Neuroendocrine tumors of the gastrointestinal tract.

Abstract: Neoplastic proliferations of neuroendocrine cells (NE) may occur throughout the entire GI tract but affect particularly appendix and ileum ("midgut carcinoids"), rectum ("hindgut carcinoids"), as well as stomach and the duodenum ("foregut carcinoids"). Only more exceptionally, they arise in the esophagus, jejunum and colon. The NE tumors encompass a heterogeneous gross and microscopic structural spectrum, ranging from inconspicuous microproliferations ("mucous membrane nevi") to bulky tumor masses. Their growth patterns are usually characteristic and easily recognized. In doubtful cases their NE differentiation becomes established by a characteristic silver affinity, by the ultrastructurally observed presence of characteristic "endocrine" secretion granules, and by immunohistochemically detectable occurrence of "pan-NE markers" (neuron-specific enolase, chromogranins, and synaptophysin), biogenic amines (mainly serotonin), and neurohormonal peptides. Foregut carcinoids usually contain serotonin, gastrin, and somatostatin, midgut carcinoids often only serotonin and tachykinins, whereas the hindgut carcinoids as a rule are multihormonal with a wide spectrum of hormonal peptides, including even insulin. Most GI NE tumors are found in the appendix (50%) and the ileum (30%). Practically all (98%) of the appendiceal NE tumors are benign. They have recently been proposed as arising from apparently Schwann-cell-related NE cells in the submucosa, whereas the ileal--and probably also all the other non-appendiceal NE tumors--are derived from the totipotential cells in epithelial crypts of the mucosa. Among the ileal NE neoplasms a large number can metastasize and result in a fatal outcome. The ability to metastasize is related to the size and to the multiplicity of the primary tumors at the time of initial diagnosis and, to some extent, to their histopathologic growth pattern. Now, some relationship between the prognosis and the cytochemically assessed nuclear DNA content of the NE tumor cells has also been established; not less than about 1/4 to 1/3 seem to be aneuploid. Almost 90% of the rectal carcinoids are benign. Exceptionally, a highly malignant NE neoplasms can arise from the colon/rectum--as well as from the esophagus--composed of NE cells of small and intermediate size. The NE tumors of the stomach are often composed of ECL (enterochromaffin-cell-like) cells; such ECL cell carcinoids are related to atrophic gastritis with pernicious anemia; experimentally, they can be induced by hypergastrinemia in rats. Duodenal carcinoids often contain psammoma bodies and can be associated with neurofibromatosis.

Accentuated formation of the terminal C5b-9 complement complex in patient plasma precedes development of the adult respiratory distress syndrome.

Abstract: Extensive studies have been conducted to determine the pathogenesis of the adult respiratory distress syndrome (ARDS) by investigating the role of complement, a mediator of inflammation. Complement activation products have been detected in blood samples from patients during ARDS. However, the individual complement components that have been assessed only indicated generalized inflammation, and none could unequivocally discriminate the onset of this acute inflammatory lung injury. In this two-year prospective study of 87 septic patients, 22 of whom developed ARDS (25%), we determined complement activation by quantifying the terminal complement complex (TCC), C5b-9. The TCC is a stable complement by-product formed following activation of either the classical or alternative pathways. Our results show that plasma TCC concentrations increased an average of 110% (p = 0.002) two days prior to the onset of ARDS and also transiently increased an average of 45% (p = 0.01) immediately preceding its resolution. Furthermore, plasma TCC concentrations were a more sensitive measure of this acute inflammatory lung injury than levels of C3a desarginine, C4a desarginine, C5a desarginine, and total hemolytic complement activity. We conclude that a temporal association exists between accentuated formation of plasma TCC and the development and also resolution of septic ARDS. Therefore, we suggest that researchers include plasma TCC concentrations in clinical studies when they could use a potential early indicator for ARDS.

Disseminated penicilliosis in a patient with acquired immunodeficiency syndrome

Abstract: We describe a case of disseminated penicilliosis in a patient with the acquired immunodeficiency syndrome. Penicillium marneffei was cultured from the blood, bone marrow, sputum, stool, and skin; the yeast forms were demonstrated in skin and bone marrow biopsy specimens. To our knowledge, this is the first reported case of disseminated penicilliosis described in a patient with the acquired immunodeficiency syndrome. The differential diagnosis with Histoplasma capsulatum is reviewed.

Salvage of infected total knee arthroplasty.

Abstract: Between 1981 and 1986, 25 patients with 26 infected total knee arthroplasties (TKAs) were treated with complete debridement of the knee, prosthetic removal, and six weeks of intravenous antibiotics, followed by insertion of a new prosthesis. The patients were followed for 12-57 months (average, 29 months). There was no evidence of residual infection at follow-up examination in any case. Applying the Hospital for Special Surgery knee rating system, 12 patients (50%) were rated excellent, six patients (25%) good, two patients (9%) fair, and four patients (6%) poor. Of the six patients with fair and poor results, five had reduced scores due to joint problems unrelated to the infected TKA. Fourteen patients had no pain at follow-up examination, and four had only slight pain. Nine patients had no limp, ten had a slight limp, one had a moderate limp, and the remainder either had a severe limp or were bedridden due to other joint problems. Eight patients could walk an unlimited distance and four could walk at least one-half mile. Twenty-one knees had a range of flexion greater than 90 degrees. Three patients had extensor lags of 20 degrees or greater. Only one patient required bracing for ambulation.

Maternal confidence in toddlerhood: its measurement for clinical practice and research.

Abstract: There are currently no measures of maternal confidence specifically for the developmental issues that arise in children between 12 months and 36 months of age. Yet, maternal confidence has been correlated with indices of maternal and child competence. The purpose of this study was to assess the reliability and validity of the Toddler Care Questionnaire (TCQ), a measure of maternal confidence in toddlerhood, for use in clinical and research settings. The data provide strong evidence that the TCQ is a reliable instrument and has validity among middle-class mothers of toddlers. The data are discussed in terms of their clinical significance and directions for future research.