- Email: [email protected]
Hot, cold, and now bubble fusion
COMMENTARY
skeletal deformities can be safely undertaken only in a multidisciplinary setting, where proper attention can also be given to all the patient’s concurrent medical problems. The implications of therapeutic procedures ought to be considered. Without a feeding gastrostomy tube some children with spastic quadriplegia would not survive long enough for hip dislocation or scoliosis to be a problem. So is the insertion of a gastrostomy tube always in the best interests of the child and the family? Painful dislocation of the hip is preceded by silent subluxation, which is easily detected and quantified by a clinical plus radiological examination.10 There is therefore the opportunity to set up hip-surveillance programmes to detect early hip subluxation in children with spastic quadriplegia, with a view to preventive surgery.11 Such surgery is effective and much less invasive than reconstructive surgery.11 Should hip surveillance be available for all children with cerebral palsy? It is probably more logical and cost effective to screen for spastic hip dislocation than for congenital hip dislocation. Once hips have dislocated, which children should have reconstructive surgery? How much is known of the natural history of hip dislocation in severe cerebral palsy? Do the benefits of invasive reconstructive surgery justify the risks? What if pre-existing respiratory disease makes the child ventilator dependent postoperatively? Close liaison between the orthopaedic surgeon, the child’s paediatrician, and the hospital’s respiratory-medicine service is thus essential for assessing risk benefits. K L Owers and colleagues provide some information on the benefits of reconstructive surgery.12 Their study in 30 children with spastic quadriplegia and severe spastic hip disease showed that combined one-stage soft-tissue and bony surgery relieved pain, corected deformities, facilitated care, and improved function. None of the patients died, and complications seemed to be self-limiting. However, death and more severe morbidity have been reported in some series. Owers and colleagues’ results are clear and convincing in terms of the technical outcomes of surgery, as asassessed by range of joint movement and radiological measurements. The most important outcomes, however, are the child’s quality of life and the burden of care experienced by the parent or carer. The surgical programme relieved pain in 85% of children, and improvements in function were obtained, as indicated by the simple but important indices of ability to sit, stand, and walk. The investigators state that functional assessment has not been standardised for these children, yet claim their methods of functional assessment were reliable. What is urgently needed is a valid and reliable measure of healthrelated quality of life for children with severe cerebral palsy.13 Orthopaedic surgery can make children different, but can it make them better? H K Graham Department of Orthopaedic Surgery, Royal Children’s Hospital, Parkville 3052, Victoria, Australia (e-mail: [email protected]) 1
2 3 4 5 6
Little WJ. On the influence of abnormal parturition, difficult labours, premature birth and asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities. Trans Obstet Soc Lond 1862; 3: 293. Rang M. The story of orthopaedics. Philadelphia: WB Saunders, 2000: 229–332. MacKeith RC, Polani PE. Cerebral palsy. Lancet 1958; 1: 61. Bax MC. Terminology and classification of cerebral palsy. Dev Med Child Neurol 1964; 6: 295–97. Ziv I, Blackburn N, Rang M, Koreska J. Muscle growth in normal and spastic mice. Dev Med Child Neurol 1984; 26: 94–99. Cosgrove AP, Graham HK. Botulinum toxin A prevents the development of contractures in the hereditary spastic mouse. Dev Med Child Neurol 1994; 36: 379–85.
908
7 8 9
10
11
12 13
Goldstein M, Harper DC. Management of cerebral palsy: equinus gait. Dev Med Child Neurol 2001; 43: 563–69. Brown JK, Minns RA. Mechanisms of deformity in children with cerebral palsy. Semin Orthopaedics 1989; 4: 236–55. Graham HK. Botulinum toxin type A management of spasticity in the context of orthopaedic surgery for children with spastic cerebral palsy. Eur J Neurol 2001; 8 (suppl 5): 30–39. Scrutton D, Baird G, Smeeton N. Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Dev Med Child Neurol 2001; 43: 586–600. Dobson F, Boyd RN, Parrott J, Nattrass GR, Graham HK. Hip surveillance in children with cerebral palsy; impact on the surgical management of spastic hip disease. J Bone Joint Surg (in press). Owers KL, Pyman J, Gargan MF, et al. Bilateral hip surgery in severe cerebral palsy. J Bone Joint Surg 2001; 83-B: 1161–67. Bjornson KF, McLaughlin JF. The measurement of health-relaated quality of life (HRQL) in children with cerebral palsy. Eur J Neurol 2001; 8 (suppl 5): 183–93.
Hot, cold, and now bubble fusion For almost 50 years now, physicists have been trying to mimic energy-producing mechanisms that the sun uses. It is very difficult to persuade two people who naturally repel each other to come together—and so it is with nuclear fusion. The hydrogen bomb, a fusion device, needs an atom bomb to get it started. Huge and very expensive experiments with “hot” fusion are still in progress, but a commercially viable machine seems as far away as ever. Then, in 1989, came “cold” fusion. Perhaps deuterium atoms would dissolve in palladium to such an extent that they would fuse without high temperatures and powerful magnets or lasers. Martin Fleischmann and Stanley Pons’s claims were controversial, to put it mildly, but research on cold fusion was to have a surprisingly long life. On March 1, 2002, Robert Park, from the American Physical Society and a scourge of what he calls “voodoo science”,1 rebuked2 Science in advance for risking a repeat of the “cold fusion fiasco” by publishing a paper by R P Taleyarkhan and colleagues on bubble fusion.3 They used a sonoacoustic method, applied to acetone in which hydrogen atoms are replaced by deuterium. The difficulty is that other scientists, using the same apparatus (apart from the neutron detector) and with the cooperation of the original researchers, have failed to find the 2·5 MeV neutrons claimed. Failure to replicate a result usually comes after publication, but at least the conflicting findings and Taleyarkhan and colleagues’ response4,5 are accessible for experts to judge for themselves. Science’s editor, Donald Kennedy, can rest easy.6 This is not an exact re-run of cold fusion. Fossil fuel reserves will be gone one day; conventional (and fusion) nuclear power still face a very uncertain future; and even if hydroelectricity or wind power were to make substantial contributions to energy needs, the environmental impact would be horrid. Original ideas are needed, even if we suspect that they are offering false hope. David Sharp c/o The Lancet, London NW1 7BY, UK 1 2
3 4
5
6
Park R. Voodoo science. Oxford: Oxford University Press, 2000. Park B. Bubble fusion: a collective groan can be heard. American Physical Society “What’s New”, March 1, 2002. http:www.aps.org/WN/ (accessed March 9, 2001). Taleyarkhan RP, West CD, Cho JS, et al. Evidence for nuclear emissions during acoustic cavitation. Science 2002; 295: 1868–73. Shapira D, Saltmarsh MJ. Comments on reported nuclear emissions during acoustic cavitation. http://www.ornl.gov/slsite (accessed March 8, 2002). Taleyarkhan RP, Block RC, West CD, Lahey RT Jr. Comments on the Shapira and Saltmarsh report. http://www.rpi.edu/~laheyr/SciencePaper.pdf (accessed March 8, 2002). Kennedy D. To publish or not to publish. Science 2002; 295: 1793.
THE LANCET • Vol 359 • March 16, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
skeletal deformities can be safely undertaken only in a multidisciplinary setting, where proper attention can also be given to all the patient’s concurrent medical problems. The implications of therapeutic procedures ought to be considered. Without a feeding gastrostomy tube some children with spastic quadriplegia would not survive long enough for hip dislocation or scoliosis to be a problem. So is the insertion of a gastrostomy tube always in the best interests of the child and the family? Painful dislocation of the hip is preceded by silent subluxation, which is easily detected and quantified by a clinical plus radiological examination.10 There is therefore the opportunity to set up hip-surveillance programmes to detect early hip subluxation in children with spastic quadriplegia, with a view to preventive surgery.11 Such surgery is effective and much less invasive than reconstructive surgery.11 Should hip surveillance be available for all children with cerebral palsy? It is probably more logical and cost effective to screen for spastic hip dislocation than for congenital hip dislocation. Once hips have dislocated, which children should have reconstructive surgery? How much is known of the natural history of hip dislocation in severe cerebral palsy? Do the benefits of invasive reconstructive surgery justify the risks? What if pre-existing respiratory disease makes the child ventilator dependent postoperatively? Close liaison between the orthopaedic surgeon, the child’s paediatrician, and the hospital’s respiratory-medicine service is thus essential for assessing risk benefits. K L Owers and colleagues provide some information on the benefits of reconstructive surgery.12 Their study in 30 children with spastic quadriplegia and severe spastic hip disease showed that combined one-stage soft-tissue and bony surgery relieved pain, corected deformities, facilitated care, and improved function. None of the patients died, and complications seemed to be self-limiting. However, death and more severe morbidity have been reported in some series. Owers and colleagues’ results are clear and convincing in terms of the technical outcomes of surgery, as asassessed by range of joint movement and radiological measurements. The most important outcomes, however, are the child’s quality of life and the burden of care experienced by the parent or carer. The surgical programme relieved pain in 85% of children, and improvements in function were obtained, as indicated by the simple but important indices of ability to sit, stand, and walk. The investigators state that functional assessment has not been standardised for these children, yet claim their methods of functional assessment were reliable. What is urgently needed is a valid and reliable measure of healthrelated quality of life for children with severe cerebral palsy.13 Orthopaedic surgery can make children different, but can it make them better? H K Graham Department of Orthopaedic Surgery, Royal Children’s Hospital, Parkville 3052, Victoria, Australia (e-mail: [email protected]) 1
2 3 4 5 6
Little WJ. On the influence of abnormal parturition, difficult labours, premature birth and asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities. Trans Obstet Soc Lond 1862; 3: 293. Rang M. The story of orthopaedics. Philadelphia: WB Saunders, 2000: 229–332. MacKeith RC, Polani PE. Cerebral palsy. Lancet 1958; 1: 61. Bax MC. Terminology and classification of cerebral palsy. Dev Med Child Neurol 1964; 6: 295–97. Ziv I, Blackburn N, Rang M, Koreska J. Muscle growth in normal and spastic mice. Dev Med Child Neurol 1984; 26: 94–99. Cosgrove AP, Graham HK. Botulinum toxin A prevents the development of contractures in the hereditary spastic mouse. Dev Med Child Neurol 1994; 36: 379–85.
908
7 8 9
10
11
12 13
Goldstein M, Harper DC. Management of cerebral palsy: equinus gait. Dev Med Child Neurol 2001; 43: 563–69. Brown JK, Minns RA. Mechanisms of deformity in children with cerebral palsy. Semin Orthopaedics 1989; 4: 236–55. Graham HK. Botulinum toxin type A management of spasticity in the context of orthopaedic surgery for children with spastic cerebral palsy. Eur J Neurol 2001; 8 (suppl 5): 30–39. Scrutton D, Baird G, Smeeton N. Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Dev Med Child Neurol 2001; 43: 586–600. Dobson F, Boyd RN, Parrott J, Nattrass GR, Graham HK. Hip surveillance in children with cerebral palsy; impact on the surgical management of spastic hip disease. J Bone Joint Surg (in press). Owers KL, Pyman J, Gargan MF, et al. Bilateral hip surgery in severe cerebral palsy. J Bone Joint Surg 2001; 83-B: 1161–67. Bjornson KF, McLaughlin JF. The measurement of health-relaated quality of life (HRQL) in children with cerebral palsy. Eur J Neurol 2001; 8 (suppl 5): 183–93.
Hot, cold, and now bubble fusion For almost 50 years now, physicists have been trying to mimic energy-producing mechanisms that the sun uses. It is very difficult to persuade two people who naturally repel each other to come together—and so it is with nuclear fusion. The hydrogen bomb, a fusion device, needs an atom bomb to get it started. Huge and very expensive experiments with “hot” fusion are still in progress, but a commercially viable machine seems as far away as ever. Then, in 1989, came “cold” fusion. Perhaps deuterium atoms would dissolve in palladium to such an extent that they would fuse without high temperatures and powerful magnets or lasers. Martin Fleischmann and Stanley Pons’s claims were controversial, to put it mildly, but research on cold fusion was to have a surprisingly long life. On March 1, 2002, Robert Park, from the American Physical Society and a scourge of what he calls “voodoo science”,1 rebuked2 Science in advance for risking a repeat of the “cold fusion fiasco” by publishing a paper by R P Taleyarkhan and colleagues on bubble fusion.3 They used a sonoacoustic method, applied to acetone in which hydrogen atoms are replaced by deuterium. The difficulty is that other scientists, using the same apparatus (apart from the neutron detector) and with the cooperation of the original researchers, have failed to find the 2·5 MeV neutrons claimed. Failure to replicate a result usually comes after publication, but at least the conflicting findings and Taleyarkhan and colleagues’ response4,5 are accessible for experts to judge for themselves. Science’s editor, Donald Kennedy, can rest easy.6 This is not an exact re-run of cold fusion. Fossil fuel reserves will be gone one day; conventional (and fusion) nuclear power still face a very uncertain future; and even if hydroelectricity or wind power were to make substantial contributions to energy needs, the environmental impact would be horrid. Original ideas are needed, even if we suspect that they are offering false hope. David Sharp c/o The Lancet, London NW1 7BY, UK 1 2
3 4
5
6
Park R. Voodoo science. Oxford: Oxford University Press, 2000. Park B. Bubble fusion: a collective groan can be heard. American Physical Society “What’s New”, March 1, 2002. http:www.aps.org/WN/ (accessed March 9, 2001). Taleyarkhan RP, West CD, Cho JS, et al. Evidence for nuclear emissions during acoustic cavitation. Science 2002; 295: 1868–73. Shapira D, Saltmarsh MJ. Comments on reported nuclear emissions during acoustic cavitation. http://www.ornl.gov/slsite (accessed March 8, 2002). Taleyarkhan RP, Block RC, West CD, Lahey RT Jr. Comments on the Shapira and Saltmarsh report. http://www.rpi.edu/~laheyr/SciencePaper.pdf (accessed March 8, 2002). Kennedy D. To publish or not to publish. Science 2002; 295: 1793.
THE LANCET • Vol 359 • March 16, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.