Lower limb amputation. Part 3: Prosthetics--a 10 year literature review

This paper is intended as a follow-up to the ISPO Consensus Conference on Amputation Surgery. It reviews all the literature on lower limb prosthetics published after 1990. The review was considered under six categories: feet, knees, hips, thermoplastics, liners/suspension and computers.

Where do patients with cancer die in Belfast?

BACKGROUND

Most patients with cancer prefer to die at home but the majority die in institutions.

AIM

To determine place of death for patients with cancer in Belfast, to examine changes over time and identify factors associated with place of death.

METHODS

A survey of deaths registered in Belfast over a six-month period for 1977, 1987 and 1997 identified patients dying from cancer. Epidemiological data included age, gender, malignancy, social class, marital status, area of residence and place of death.

RESULTS

Home deaths fell from 35% in 1977 to 28% in 1997. Hospital deaths fell from 50% in 1977 to 40% in 1987 rising to 42% in 1997. Hospice deaths rose from 13% in 1977 to 25% in 1987 falling to 23% in 1997. There was an association between place of death and age, marital status, type of cancer and area of residence, but not with social class or gender.

CONCLUSION

The majority of people fail to achieve a home death. Resources need to be targeted to those most at risk of an institutional death; females, the elderly, the unmarried, those with haematological malignancies and residents of South Belfast.

Methylenetetrahydrofolate reductase 677 C-->T mutation and coronary heart disease risk in UK Indian Asians

Plasma homocysteine concentrations are elevated in UK Indian Asians and may contribute to twice as many coronary heart disease (CHD) deaths in this group compared with European whites. The mechanisms underlying elevated homocysteine concentrations among Indian Asians are not well understood. In this study, we have investigated the extent to which the methylenetetrahydrofolate reductase (MTHFR) 677 C-->T mutation accounts for elevated plasma homocysteine and increased CHD risk in Indian Asians compared with European whites. We investigated 454 male cases (with myocardial infarction or angiographically proven CHD: 224 Indian Asians, 230 European whites) and 805 healthy male controls (381 Indian Asians, 424 European whites). Fasting homocysteine concentrations, MTHFR 677 C-->T genotype, and conventional CHD risk factors were measured. The prevalence of homozygous MTHFR 677T in Indian Asian controls was less than one third that in European white controls (3.1% versus 9. 7%, P<0.001). In Indian Asians, the TT MTHFR genotype was not associated with homocysteine concentrations and was not present in any of the Asian controls with hyperhomocysteinemia (>15 micromol/L). In contrast, among European whites, the TT MTHFR genotype was strongly related to elevated plasma homocysteine concentrations and was found in 27% of the European controls with hyperhomocysteinemia. Elevated homocysteine in Indian Asian compared with European white controls was accounted for by their reduced levels of B vitamins but not by the MTHFR 677T genotype. However, neither the TT MTHFR genotype nor B vitamin levels explained the elevated homocysteine concentrations in CHD cases compared with controls. TT MTHFR was not a risk factor for early-onset CHD in Indian Asians (odds ratio, 0.5; 95% confidence interval, 0.1 to 2.4; P=0.39), unlike in European whites (odds ratio, 2.1; 95% confidence interval, 1.1 to 4. 1; P=0.02). We conclude that the MTHFR 677T: mutation does not contribute to elevated plasma homocysteine concentrations or increased CHD risk in Indian Asians compared with European whites. Our results suggest that novel genetic defects and/or environmental factors influence homocysteine metabolism in Indian Asians residing in the United Kingdom.

Upregulation of amyloid precursor protein and its mRNA in an experimental model of paediatric head injury

Amyloid precursor protein (APP), a membrane spanning glycoprotein which plays an important role in neuronal growth and synaptic plasticity, is increased after traumatic brain injury (TBI) and has been used as a sensitive marker of neuronal damage in an adult sheep head impact model. We hypothesised that APP expression would similarly be increased in lambs, suggesting that in the immature injured brain APP is also upregulated as an acute phase response to trauma. Ten anaesthetised and ventilated 4-5 week old Merino lambs sustained a left temporal head impact from a humane stunner. At 2 h after impact, there was widespread and intense neuronal cell body APP immunoreactivity which was more widely distributed than axonal APP. APP messenger RNA (mRNA) expression was also markedly increased with a distribution similar to that of APP antigen. These results demonstrate that APP antigen and mRNA are sensitive early indicators of TBI in paediatric cases.

Gunshot wounds below the popliteal fossa: a contemporary review

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.

Determining cerebral perfusion pressure thresholds in severe head trauma

Laboratory studies suggest the pulsatile component of the transcranial doppler (TCD) waveform may be useful in determining lower autoregulatory threshold. This study aimed to assess the effect of increasing CPP on jugular bulb oximetry (SjO2) and middle cerebral artery (MCA) TCD flow velocities in the early management of severe head injury. 16 severely head injured patients (GCS < or = 8), had intracranial pressure (ICP), mean arterial pressure, SjO2 and MCA Doppler velocity monitored continuously. CPP was increased by intravenous fluids (right atrial pressure approximately equal to 10) and supplemented with adrenaline infusion until TCD pulsatility (Gosling pulsatility index [PI] reached a plateau. The mean CPP at which SjO2 surpassed 55% was 62 +/- 6.2 mm Hg. TCD PI did not plateau until a significantly higher mean CPP of 74 +/- 5.1 mm Hg was achieved (p < 0.01). In 8 cases, increased CPP was associated with a fall in ICP, ranging from 1 to 8 mm Hg. We conclude that a critically low level of SjO2 is a late indicator of failed autoregulation. CPP values associated with intact autoregulation identified by TCD assessment of MCA flow are significantly higher than those indicated by SjO2 monitoring. MCA Doppler flow assessment may be useful in determining the level of CPP at which therapy should be aimed in the early resuscitation of head trauma.

Diffuse neuronal perikaryon amyloid precursor protein immunoreactivity in a focal head impact model

Amyloid precursor protein (APP) has been shown to accumulate in traumatically injured axons as early as 1 hour after injury. This accumulation may be due to interruption of fast axoplasmic transport and/or upregulation of APP synthesis. The aim of this study was to examine the neuronal cell body response to head impact using APP immunostaining in a focal non-missile head impact model. Ten anaesthetised and ventilated 2 year old Merino ewes were subjected to graded impact in the left temporal region by captive bolt. 2 hours after impact the brain was perfused fixed with formaldehyde. The tissue was mounted in paraffin, sectioned and stained with a monoclonal antibody to APP and standard H&E stain. APP positivity was semi-quantitated using a modification of our previously described sector scoring system [1]. Widespread neuronal APP positivity was found in the cerebral hemispheres and brain stem distant from the site of focal injury in all 10 animals. The most prominent APP positivity was found in the nerve cell bodies of the impacted left cerebral hemisphere. APP positive neurons were also found within regions which were structurally normal when stained with H&E. These results demonstrate diffuse neuronal perikaryon APP immunoreactivity following a focal head impact injury. The expression of APP within the neuronal cell body may be due to upregulation of APP synthesis or alterations in the availability of epitopes of APP. Further studies are in progress to address these hypotheses.

Teenage mothers and their peers: a research challenge

Recent reports have highlighted the adverse health experience of teenage mothers. The question of how these mothers' perceptions of their own health status and social networks differ from those of their nulliparous peers is explored in this pilot study, which highlights some practical problems associated with research in this important field.

A clinical trial of a financial incentive to go to the tuberculosis clinic for isoniazid after release from jail

SETTING

Screening for active tuberculosis (TB) and providing isoniazid (INH) preventive therapy in jails are important control measures. In San Francisco, however, historical data showed that 62% of inmates were released before completing preventive therapy, and of those only 3% attended the TB Clinic for follow-up.

OBJECTIVE AND DESIGN

A randomized clinical trial to compare a $5 cash incentive plus standardized TB education with standardized TB education alone in encouraging released inmates to make a first visit to the clinic.

RESULTS

Of 79 persons enrolled in the trial, 77.2% were released before INH completion. Rates of first visit were not significantly different for those receiving +5 plus standardized education (25.8%) versus standardized education alone (23.3%), but were higher than rates seen in historical data for inmates not receiving standardized education. Age was an important predictor of completion of a first visit (odds ratio 1.09, 95% confidence interval 1.02-1.16, P = 0.017). Other variables predicting adherence included intent to adhere, more previous time in jail, stable housing, and being partnered versus alone, although these were not statistically significant.

CONCLUSION

Standardized education may be important in improving follow-up after release. Further work on the role of a financial incentive in this population is needed.

Long-term in vivo cochlear transgene expression mediated by recombinant adeno-associated virus

Adeno-associated virus (AAV) integrated transgene expression within guinea pig cochlea has been previously documented. This article extends these studies by characterizing the AAV-mediated gene transfer for duration of transgene expression within the cochlea and its effect upon cochlear cytoarchitecture over a period of 6 months. All animals infused with AAV expressed the transgene product, bacterial beta-galactosidase (beta-gal) enzyme, in the spiral limbus, spiral ligament, spiral ganglion cells and the organ of Corti at 2-24 weeks after infusion. However, the level of beta-gal expression, as determined from intensity of immunoreactivity, was relatively lower at 24 weeks as compared with 2 weeks. The cellular and tissue architecture within the AAV-beta-gal perfused cochleae, harvested 2-8 weeks after AAV infusion, was generally intact, ie free from inflammation and cellular degeneration. However, cellular degeneration and degradation was apparent in the cochleae of some but not all animals harvested at 12 and 24 weeks after AAV infusion.

A software architecture to support a large-scale, multi-tier clinical information system

A robust software architecture is necessary to support a large-scale multi-tier clinical information system. This paper describes our mechanism for enterprise distribution of applications and support files, the consolidation of data-access functions and system utilities stored on the data access tier, and an application framework which implements a coherent clinical computing environment. The software architecture and systems described in this paper have been robust through pilot testing of our applications at Massachusetts General Hospital.

Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting

BACKGROUND

Approximately 32 000 nonpowder firearm injuries are reported annually with more than 60% occurring in the pediatric population. Case reports of serious and fatal injuries have been described; however, no large inclusive series have been published. We reviewed an 11-year experience of an urban pediatric emergency department to evaluate the circumstances, spectrum of injuries, and outcomes attributable to nonpowder firearms.

METHODS

A retrospective, descriptive case series of all children 18 years of age or younger evaluated at an urban children's hospital from January 1983 through December 1994 were eligible for study. Patients were identified using a computerized database, the National Electronic Injury Surveillance System, and the trauma registry in the department of surgery. Medical records were reviewed to collect demographic information, circumstances of injury, anatomic site and type of injury, treatment, and outcomes for nonpowder firearm injuries.

RESULTS

One hundred eighty patients were identified, and a complete data set was available for 166 (92%). The mean age was 12 +/- 3.7 years, 24% of children were <10 years old, and 71% of the children were male. Three patients returned with a second nonpowder firearm injury during the study period. Forty-nine percent of injuries were intentional and 44% of all injuries occurred during the summer and early fall months. The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation). The majority of wounds required local wound care, and the children (74%) were discharged from the emergency department. Of the patients admitted to the hospital (27%), 45% required operative intervention. There were no deaths. Seven percent (12/166) of patients sustained some functional deficit with 42% (5/12) the result of an ocular injury.

CONCLUSION

The majority of nonpowder firearm injuries are minor; however, the potential for serious injury should not be underestimated. Minor injuries can be treated with local wound care and tetanus prophylaxis, and patients can be discharged from the emergency department. Education of parents and children to the potential risks associated with these weapons is essential. Stricter regulations regarding ownership of nonpowder firearms and mandatory safety instruction should be considered.

Mice lacking the myotonic dystrophy protein kinase develop a late onset progressive myopathy

Myotonic dystrophy (DM) is an autosomal dominant disorder resulting from the expansion of a CTG repeat in the 3' untranslated region of a putative protein kinase (DMPK). To elucidate the role of DMPK in DM pathogenesis we have developed Dmpk deficient (Dmpk-/-) mice. Dmpk-/-mice develop a late-onset, progressive skeletal myopathy that shares some pathological features with DM. Muscles from mature mice show variation in fibre size, increased fibre degeneration and fibrosis. Adult Dmpk-/-mice show ultrastructural changes in muscle and a 50% decrease in force generation compared to young mice. Our results indicate that DMPK may be necessary for the maintenance of skeletal muscle structure and function and suggest that a decrease in DMPK levels may contribute to DM pathology.

General practice data retrieval: the Northern Ireland project

OBJECTIVE

To develop an epidemiological database of morbidity in the community as presented to general practitioners and to support epidemiological research in general practice.

DESIGN

The project is a sentinel network of 23 general practices in Northern Ireland that report the incidence of a list of selected diseases to a central unit for analysis.

RESULTS

Results are presented for depression, diabetes, and myocardial infarction. The age--sex distributions of diabetes and myocardial infarction are comparable with other published data but the incidence of depression is under estimated.

CONCLUSIONS

The importance of complete accuracy of data reported within sentinel networks depends on the purposes for which information is to be used. For some diagnoses, such as diabetes and acute myocardial infarction, the accuracy of the reported incidence is high while for other diseases, such as depression, where diagnostic behaviour varies more between doctors, the figures are much less reliable.

The hemostatic effects of desmopressin on patients who had total joint arthroplasty. A double-blind randomized trial

The effects of desmopressin on postoperative bleeding and postoperative transfusion requirements were studied in ninety-two hemostatically normal patients who had had an elective primary total hip or total knee arthroplasty. The patients were randomized into either a placebo or a desmopressin group in a double-blind prospective clinical trial. During closure of the wound, desmopressin (0.03 microgram per kilogram of body mass) or the placebo was infused into a peripheral vein over a twenty-minute period. Compared with the placebo, desmopressin did not significantly decrease blood loss or transfusion requirements, and it did not affect the postoperative platelet or fibrinogen levels or the bleeding time. The results were no different even when the treatment and control groups were matched according to surgeon, use of cement for the femoral and knee components, preoperative use of non-steroidal anti-inflammatory agents, or performance of a lateral release for total knee arthroplasty. We concluded that desmopressin does not reduce blood loss or transfusion requirements after total joint arthroplasty.

Immunocytochemical analysis of poly-beta-hydroxybutyrate (PHB) synthase in Alcaligenes eutrophus H16: localization of the synthase enzyme at the surface of PHB granules

Antibodies raised against the Alcaligenes eutrophus poly-beta-hydroxybutyrate (PHB) synthase polypeptide were used for immunocytochemical localization of the synthase enzyme in whole cells and purified PHB granules. The data presented demonstrate for the first time that the synthase enzyme is located on the surface of the PHB granule rather than being incorporated inside the granule during its formation. From these basic observations and data from the recent literature, a model of granule assembly is proposed.