Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria

High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-1) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

Regional five-year clinical outcomes of 289 consecutive cementless oxford uni-compartmental knee replacements at a non-inventor centre

INTRODUCTION

Uncemented unicompartmental knee replacement offers a minimally invasive approach, faster rehabilitation and good levels of function, supported by evidence reporting low intra-operative fracture rate and mid-term stability with no implant migration at 5-years. Our aim was to examine the clinical outcomes in 289 consecutive Oxford unicompartmental knee arthroplasties (257 patients), five years post-operatively.

METHODS

A retrospective study of patients treated between 2008 and 2014 in a non-inventor centre by a single surgeon was performed. Patients with anteromedial bone on bone uni-compartmental arthritis were included. Oxford Knee Scores (OKSs) at last follow-up were recorded, intra-operative complications reported with commentary on revision cases.

RESULTS

Mean age of patients was 66 years (SD 9.6, 45-88 years). 122 (42%) patients were female and 135 (58%) were male. Patient in our study were ASA 1 (36%), ASA 2 (62%) and ASA 3 (01%). There were no intra-operative complications, particularly tibia fractures during impaction. The average oxford knee score was 40.1 (n = 232, Range 06 to 48, SD 8.46) at an average 6 years and 3 months from surgery, including revised patients. Six patients had their prosthesis revised within five-years of the index surgery. Five-year cumulative implant survival rate was 97.8% (95% CI 97.62 to 97.98, SE 0.09). Indications for revision were: lateral side wear (n = 1); dislocated spacer (n = 4); instability and spacer subluxation (n = 1). Thirteen patients died within five years of surgery Five-year cumulative survival rate was 94.9% (95% CI 94.87 to 94.925, SE 0.013).

CONCLUSION

The proportion of patients requiring revision at five-years is lower than that generally reported for UKR. These findings add support for the use of the cementless oxford UKR outside the design centre.

Cornus macrophylla, the Antibacterial Activity of Organic Leaf Extracts and the Characterization of the More Lipophilic Components by GC/MS

In the present study, the antibacterial activity of Cornus macrophylla was examined. Organic solvent extracts of leaves were prepared using methanol, n-hexane, chloroform, and ethyl acetate. Antibacterial activity was examined by using a 100 mg/mL extract concentration. Penicillin was kept as a positive control while dimethyl sulfoxide was taken as a negative control. Methanolic extract exhibited a 21.5, 36.3, 25.3, and 23.7 mm inhibition zone diameter (IZD); n-hexane showed a 33, 40, 32.8, and 28.7 mm IZD; chloroform showed a 18.8, 29, 22.3, and 21.6 mm IZD; and ethyl acetate showed a 23.5, 30.2, 30, and 22.3 mm IZD against Erwinia carotovora, Pseudomonas syringae, Ralstonia solanacearum, and Xanthomonas axonopodis, respectively. The n-hexane extract revealed high antibacterial activity against all bacterial species as compared with methanolic, chloroform, and ethyl acetate extract. Gas Chromatography Mass Spectrometry (GC/MS) analysis of n-hexane extract depicted the presence of 55 compounds. Out of these compounds, one compound, identified as α-amyrin (Mol. wt = 426), exhibited the maximum peak area (32.64%), followed by A'-Neogammacer-22(29)-en-3-ol, acetate, (3.beta.,21.beta.)- (Mol. wt = 468) and β-amyrin (Mol. wt = 426) having peak areas of 25.97 and 6.77%, respectively. It was concluded that the antibacterial activity observed during the present investigation may be due to these compounds.

P1727 Large coronary artery to pulmonary artery fistula as primary source of pulmonary blood supply in tetralogy of fallot with pulmonary atresia

Funding Acknowledgements

Not Applicable

OnBehalf

Not Applicable

Introduction

Pulmonary blood supply in patients of Tetralogy of Fallot with pulmonary atresia is usually from patent arterial duct or major aortopulmonary collaterals (MAPCAs) arising from descending thoracic aorta. We describe a case in which large coronary to pulmonary artery fistula was the primary source of pulmonary blood supply.

Case Report

A 17 years old female was referred to our hospital for diagnostic workup of suspected congenital heart disease. She was previously undiagnosed and now complains of progressive shortness of breath for last few months.

On physical examination she was non-dysmorphic with oxygen saturation of ∼ 77 % in room air, blood pressure of ∼ 117/72 mmHg, pulse rate of ∼ 89 beats per minute and respiratory rate of ∼ 24 breaths per minute. She was clinically cyanosed with grade 3 clubbing and polycythemic. Cardiovascular examination revealed quiet precordium with normally placed apex beat, grade 2 parasternal heave with single second heart sound and grade 3/6 continuous murmur along left mid sternal border.

Twelve lead electrocardiogram (ECG) showed normal sinus rhythm, right axis deviation and right ventricular hypertrophy. There was no evidence of ischemia. Chest X-ray revealed "boat shaped heart" with oligaemic lung fields. Transthoracic echocardiography showed large conoventricular ventricular septal defect with bidirectional flow. There was aortic over-ride with dilated left main coronary artery. No forward flow was seen across right ventricular outflow tract. Considering hugely dilated left main coronary artery, suspicion of coronary to pulmonary artery fistula was made and cardiac computed tomography followed by conventional angiography was done, both confirmed the diagnosis of Tetralogy of Fallot with pulmonary atresia and large coronary artery to main pulmonary artery fistula as a primary pulmonary blood supply. Two small collaterals (MAPCAs) were also identified supplying small part of right and left lungs.

Conclusion

This case highlights unusual source of pulmonary blood supply in Tetralogy of Fallot with pulmonary atresia. Correct pre-operative diagnosis is essential for appropriate surgical planning and better outcome.

Abstract P1727 Figure. TOF-PA with CA to PA Fistula

Perspectives on the production of milk on small-holder dairy farms and its utilisation in developing countries

The profitability of milk production in the developing world varies widely among farming systems. This results from poor animal productivity and an inefficient marketing-chain structure in which farmers seldom profit from their dairying activities. The lack of chilling facilities for milk storage and the need to adulterate the raw product along the market chain to enhance profit margins means that consumers are not well catered for. Co-operative selling of milk, along with the acquisition of higher-quality feeds and veterinary medicines, has boosted the financial resilience of small-holder farming communities worldwide, although, in many regions, the co-operative model has not succeeded largely through a lack of trust between families even within the communities. Commercial reality dictates that farming communities work together to achieve financial sustainability, although the model adopted for each community may differ. Although milk has traditionally provided many consumers with their only source of animal protein, vitamin and minerals, we are now discovering its many other virtues, particularly in relation to cognitive development and memory retention and the provision of antioxidants. The impact of milk-processing technology on some of these remarkable properties requires further investigation to ensure that milk consumers worldwide benefit from these positive attributes.

Effect of Hemodialysis on Corrected QT Interval and QTc Dispersion

Hemodialysis patients are at higher risk of cardiovascular disease due to traditional and dialysis-related risk factors. Our aim was to study the effects of hemodialysis on the corrected QT interval (QTc) and QTc dispersion in chronic kidney disease (CKD) without clinically manifest heart disease. Two hundred cases of CKD on chronic intermittent hemodialysis of >3 months' duration were included in the study. Twelve-lead electrocardiography and samples for serum creatinine, potassium, calcium, and magnesium were taken before and after dialysis. The mean age of patients was 52.4 ± 17 years with male-to-female ratio of 3:1. QTc interval and QTc dispersion were prolonged in 47% and 59% before and 50% and 89% of patients after hemodialysis, respectively. The mean values of QTc were 433.4 ± 36.9 ms before and 451.4 ± 39.6 ms after hemodialysis (p = 0.001) and the mean values of QTc dispersion were 60.5 ± 19.3 ms before and 81.5 ± 24.4 ms after hemodialysis (p = 0.001). Similar pattern was observed in all etiological groups of CKD, except for QTc dispersion in malignancy-related CKD (p = 0.216). After hemodialysis, there was a significant fall in the mean values of serum potassium (p = 0.001), rise in serum calcium (p = 0.001), and no change in magnesium (p = 0.424). Patients with post hemodialysis QTc dispersion >74 ms had significantly low mean values of serum potassium and calcium as compared to <74 ms group. Large numbers of hemodialysis patients have a prolonged QTc interval and QTc dispersion with a significant increase in the mean values after hemodialysis. There is a significant fall in serum potassium and rise in serum calcium after dialysis.

Cytomegalovirus-Induced Polyarteritis Nodosa in a Liver Transplant Recipient

Polyarteritis nodosa (PAN) is a necrotizing vasculitis that has been associated with viral infections, especially hepatitis B virus. We hereby report a case of tissue-invasive cytomegalovirus (CMV)-induced PAN in a liver transplant recipient presenting with acute kidney injury and active urinary sediment. Treatment directed against both PAN and CMV resulted in improvement in kidney function, normalization of urinary indices and resolution of the CMV infection. There was no recurrence of either PAN or CMV after a 3-year follow-up period.

Special care dentistry: how prepared are we?

AIM

To assess and evaluate the confidence of the undergraduate dental team in Irish dental schools regarding their training in the field of special care dentistry (SCD).

METHOD

A questionnaire was distributed amongst the undergraduate dental teams within Cork University Dental School and Hospital (CUDSH) and Dublin Dental University Hospital (DDUH). The data were analysed to assess for differences between the median responses of the various groups.

RESULTS

A total of 139 students participated in the study; 82 from DDUH (59 dental science students, seven dental hygiene students and 16 dental nursing students) and 57 from CUDSH (43 dental science students and 14 dental hygiene students). Twenty-two per cent (n = 30) of respondents agreed that their training had been sufficient in providing treatment or assistance for patients requiring SCD. Seventy-five per cent agreed that more emphasis should be placed on clinical training in SCD (n = 76). Thirty-one per cent of students anticipated a high level of confidence in treating patients requiring SCD upon graduation (n = 43), with dental science students feeling the least prepared amongst the dental team.

CONCLUSION

Confidence levels of the undergraduate dental team were low with regard to SCD. The existing hands-on clinical training in SCD was deemed insufficient by the respondents. Students believed more emphasis should be placed on SCD training in the undergraduate curriculum.

Transfer of aflatoxins from naturally contaminated feed to milk of Nili-Ravi buffaloes fed a mycotoxin binder

The objectives of this study were to observe the extent of transfer of aflatoxin B1 in feed to the aflatoxin M1 metabolite in milk in Nili-Ravi buffaloes and to evaluate the efficacy of a commercial mycotoxin binder (Mycofix, Biomin Singapore) incorporated into feed to minimise this transfer. Multiparous animals (n = 28) were randomly distributed to four groups corresponding to two treatments each with two levels of aflatoxin B1. Individual animals were exposed to naturally contaminated feed providing a total of 1475 µg/day (Groups A and B) or 2950 µg/day (Groups C and D) of aflatoxin B1. Groups B and D were given 50 g of mycotoxin binder daily mixed with feed whereas Groups A and C were kept as controls. Feed samples were analysed by reverse phase high performance liquid chromatography for aflatoxin B1 and milk samples were evaluated by enzyme-linked immunosorbent assay for the liver metabolite aflatoxin M1. The mean value of total daily aflatoxin M1 excretion for animals fed 2950 µg/day of aflatoxin B1 (112.6 µg/day) was almost double (P < 0.001) than the excretion in buffaloes fed 1475 µg/day (62.2 µg/day). The mean daily concentration of aflatoxin M1 in milk of animals from both treatment groups supplemented with 50 g/day of mycotoxin binder was 76.5 µg/day, nearly 22 µg lower than those without binder at 98.3 µg/day (s.e.d. = 5.99: P < 0.01). The interaction of binder and treatment was not significant i.e. the 50 g/day of binder was able to sequester aflatoxin B1 with the same efficiency in groups fed with high and low concentrations of aflatoxin B1. Carry over was (3.44%) lower (P = 0.001) in animals supplemented with 50 g/day of mycotoxin binder than those fed no binder (4.60%). Thus buffaloes are highly efficient at transferring aflatoxins in feed to the aflatoxin M1 metabolite in milk, whereas mycotoxin binder is capable of alleviating without preventing this contamination risk.

Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study

Glomerular diseases continue to be the leading cause of end-stage renal disease (ESRD) globally. Hence, it is important to recognize the pattern of glomerular diseases in different geographical areas in order to understand the patho-biology, incidence and progression of the disorder. Published studies from different centers in Saudi Arabia have reported contradicting results. In this retrospective study, we report our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia. A total of 348 native renal biopsies performed at our center on patients with proteinuria >1 g, hematuria and/or renal impairment during a period of 5 years (between January 2005 and December 2009) were studied by a histopathologist using light microscopy, immunofluorescence and electron microscopy, and were categorized. Results showed that primary glomerular disease accounted for 55.1% of all renal biopsies. The most common histological lesion was focal and segmental glomerulosclerosis (FSGS) (27.6%), followed by minimal change disease (MCD) (17.7%) and membrano-proliferative glomerulonephritis (MPGN) (13.0%). Secondary glomerular disease accounted for 37.9% of the glomerular diseases, with lupus nephritis (LN) being the most common lesion (54.5%), followed by hypertensive nephrosclerosis (22%), post-infectious glomerulonephritis (7.5%), diabetic nephropathy (DN) (6.8%) and vasculitides (4.5%). Four percent of all biopsies turned out to be ESRD while biopsy was inadequate in 2.8% of the cases. In conclusion, our study showed that FSGS was the most common primary GN encountered, while LN was the most common secondary GN. We encountered 14 cases of crescentic glomerulonephritis. Also, the prevalence of MPGN, MCD, IgA nephropathy and membranous GN was many folds higher in males when compared with the Western data. We believe that it is mandatory to maintain a Saudi Arabian Renal Biopsy Registry to understand better the pattern of glomerular disease in the Saudi population and to follow any change in trend.

Pattern of partitioning of aflatoxins from feed to urine and its effect on serum chemistry in Nili-Ravi buffalo heifers

The objectives of the present study were (1) to monitor the pattern of excretion of aflatoxinM1 in urine after its conversion from aflatoxinB1 and (2) to observe the effects of different levels of aflatoxinB1 in feed on serum concentrations of key metabolites glucose, total protein, cholesterol and urea as indicators of metabolic status. Nili-Ravi buffalo heifers (n = 12) of similar age and weight were randomly distributed to four groups. Animals in Groups A, B and C were offered a contaminated cottonseed cake-based concentrate ration at 0.5%, 1.0% and 1.5% of bodyweight, respectively. Control animals in Group D were fed with aflatoxinB1-free green fodder. Based on the level of contamination of the concentrate ration with aflatoxinB1 (554 µg/kg), Groups A, B and C consumed 953, 2022, 3202 µg of aflatoxinB1 daily. Feed samples were analysed at Romer Laboratories Pty Ltd, Singapore by high performance liquid chromatography. AflatoxinM1 quantification in urine samples was conducted using a competitive enzyme-linked immunosorbent assay with kits supplied by Helica Biosystems, Inc., USA. Serum samples were analysed for concentrations of glucose, total protein, cholesterol and urea using clinical chemistry kits provided by Human diagnostics (HUMAN, Biochemica und Diagnostica mbH, Germany). Carry-over rate of aflatoxinM1 in urine for Groups A, B and C was 15.51%, 15.44% and 14.04% of aflatoxinB1 while there was no detectable aflatoxinM1 in the urine of the control group (D). There was no significant difference in the concentrations of serum glucose, total protein and cholesterol between treatment groups. However, the concentration of serum urea was significantly higher (P < 0.05) in the group offered the highest level of aflatoxinB1-contaminated concentrate. This result suggests that mycotoxicosis may compromise protein metabolism and accretion in affected animals. This leaves open the possibility that high concentrations of aflatoxins in milk may ultimately affect the health status of human milk consumers.

Outcome of arthrodesis of the hindfoot as a salvage procedure for complex ankle pathology using the Ilizarov technique

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

Profile of drug users in Karachi City, Pakistan

Drug use has been identified as a major public issue in Pakistan. A descriptive questionnaire survey in Karachi city was made to identify the socioeconomic profile and beliefs and practices of 500 drug users The most commonly used drugs were cocaine (19.0%) and crack-cocaine (15.0%), followed by amphetamine, (11.0%), alcohol, caffeine, barbiturates and benzodiazepines (10.0% each). Key psychological factors leading tc drug use were problems with parental or marital relations or break-up of a relationship (45.0%). Drugs were seer as an escape from stressful life events (28.0%) or feelings of failure (18.2%). Many drug users blamed the origin of their drug use on bad social influences (47.0%) or socioeconomic problems (23.4%). Preventive measures are needed to decrease the rate of drug addiction in Karachi.

A comparative study of the risk of malignancy index and the ovarian crescent sign for the diagnosis of invasive ovarian cancer

OBJECTIVE

To compare the value of the risk of malignancy index (RMI) and the ovarian crescent sign (OCS) in the diagnosis of ovarian malignancy.

METHODS

This was a prospective observational study of women with ultrasonographic diagnosis of an ovarian cyst. The RMI was calculated in all cases using a previously published formula (RMI = U (ultrasound score) x M (menopausal status) x serum CA125 (kU/L)). A value > 200 was considered to be diagnostic of ovarian cancer. The OCS was defined as a rim of visible healthy ovarian tissue in the ipsilateral ovary. Its absence was taken as being diagnostic of invasive cancer.

RESULTS

A total of 106 consecutive women were included in the study, of whom 92 (86.8%) had a benign ovarian tumor, five (4.7%) had borderline lesions and nine (8.5%) had an invasive ovarian cancer. The absence of an OCS diagnosed invasive ovarian cancer with a sensitivity of 100% (95% CI, 70-100%), specificity of 93% (95% CI, 86-96%), positive predictive value (PPV) of 56%, negative predictive value (NPV) of 100% and positive likelihood ratio (LR+) of 13.86 (95% CI, 6.79-28.29). This compared favorably with a sensitivity of 89% (95% CI, 57-98%), specificity of 92% (95% CI, 85-96%), PPV of 50%, NPV of 99% and LR+ of 10.78 (95% CI, 5.34-21.77), which were achieved using RMI > 200 (P < 0.01).

CONCLUSIONS

The RMI and the OCS are useful tests for discriminating between invasive and non-invasive ovarian tumors. The application of these tests in a sequential manner might improve the overall accuracy of ovarian cancer diagnosis.

Predictors of Mortality in End-Stage Renal Disease Patients with Mitral Annulus Calcification

OBJECTIVE

Mitral annulus calcification (MAC) is an independent predictor of cardiovascular mortality in the general population. The purpose of the current historical cohort study is to assess risk factors for long-term mortality in end-stage renal disease (ESRD) patients with MAC (n = 30; age, 62 +/- 2 yr), as compared to ESRD patients without MAC (n = 30; age, 63 +/- 2 yr). Additional analysis compared ESRD patients with MAC to non-ESRD patients with MAC (n = 32; age, 66 +/- 2 yr).

METHODS

The groups included age-matched male patients followed at a single center. Long-term survival was assessed by Kaplan-Meier analysis. Regular and stepwise Cox proportional hazards models were used to determine risk factors for mortality.

RESULTS

There was a similarly high prevalence of cardiovascular complications, including hypertension, coronary artery disease, left ventricular hypertrophy, atrial fibrillation, and congestive heart failure, in all three groups. Median survival time was significantly longer in non-ESRD patients (90 months), compared with the ESRD with MAC (45 months) and ESRD without MAC (45 months) patients (log-rank test; P < 0.001). With stepwise Cox proportional hazards model, including ESRD patients with MAC and ESRD patients without MAC, increased calcium x phosphate product, decreased serum creatinine concentration, and the presence of coronary artery disease and lower extremity amputations were independent predictors of mortality for patients with ESRD. With stepwise Cox proportional hazards model, including ESRD patients with MAC and non-ESRD patients with MAC, the presence of ESRD, atrial fibrillation, diabetes, aortic valve calcification, coronary artery disease, and tricuspid regurgitation were independent predictors of mortality.

CONCLUSION

The mortality rate was high in ESRD patients, approximately 15% per year. After accounting for baseline cardiovascular disease and traditional risk factors, the presence of MAC did not confer additional risk for mortality.

The effects of hyaluronic acid on articular chondrocytes

The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism in vitro. The clinical benefits of intra-articular hyaluronic acid injections are thought to occur through improved joint lubrication. Recent findings have shown that exogenous hyaluronic acid is incorporated into articular cartilage where it may have a direct biological effect on chondrocytes through CD44 receptors.Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes. There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes in vitro. Low concentrations of hyaluronic acid (0.1 mg/mL and 1 mg/mL) significantly increase DNA, sulphated glycosaminoglycan and hydroxyproline synthesis. Immunohistology confirmed the maintenance of cell phenotype with increased matrix deposition of chondroitin-6-sulphate and collagen type II. These findings confirm a stimulatory effect of hyaluronic acid on chondrocyte metabolism.

The false profile arthrogram in developmental dysplasia of the hip

Arthrography is useful in the evaluation and treatment of developmental dysplasia of the hip. The authors describe the additional diagnostic value obtained from a "false profile" arthrogram. The "false profile" arthrogram allows assessment of anterior acetabulum cover, femoral neck anteversion and hip joint subluxation (instability), which may not be apparent on other views. (Hip International 2005; 15: 177-81).

Iliofemoral distraction and hip reconstruction for the sequelae of a septic dislocated hip with chronic femoral osteomyelitis

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

Mechanisms and pattern of facial lacerations in the Accident Department

The purpose of this study was to determine patterns of facial laceration seen in the Accident and Emergency Department and identify how they are related to the mechanism of injury. A retrospective analysis of facial lacerations of an adult presenting to Accident and Emergency department was made over a 6-month period. There were 197 consecutive facial lacerations. The mean age of patients was 46 years. There were 137 male and 60 female patients. The aetiology of lacerations was falls (48%), assaults (11%), hit by an object by accident (21%) and hit stationary object by accident (15%). Mechanism of injury was found to be related to common patterns of laceration. Lacerations affecting the forehead mainly occurred in falls and those affecting the peri-orbital and peri-oral areas in assault. Lacerations were mainly linear, with a mean length of 2.4 cm, and about 75% were precipitated by blunt injury. Identification of common patterns of injury corresponding to a certain mechanism may allow assessment of the difficult or non-compliant patient. Understanding mechanisms of injury will allow safety planners to design safer domestic and workplace environments.

Ulnar tunnel syndrome due to anatomical variant of the ulnar artery

We report a case of ulnar tunnel syndrome due to an anatomical variant branch of the ulnar artery. Anatomical variants can cause compression not visible on imaging and need to be considered for successful surgical decompression.

Multiple schwannomas of the median nerve: a case report and literature review

We report a case of multiple schwannomas of the median nerve. Multiple schwannomas can be difficult to diagnose on clinical grounds and can be mistakenly diagnosed as carpal tunnel syndrome or ganglia as in our case. Nerve conduction studies helped locate non-visible tumours. Magnetic resonance imaging (MRI) is useful in the preoperative planning of these tumours. The appearances on scanning however can be sometimes confused for ganglia as in this case. Intraneural dissection of the schwannomas was carried out and the pathology is described.

Regional audit: perioperative management of MRSA orthopaedic patients in the Oxford region

AIM

Methicillin resistant staphylococcus aureus (MRSA) colonisation or infection is of particular importance in patients undergoing operations involving implantable materials, such as in orthopaedic surgery. An audit of the perioperative management of orthopaedic patients in the Oxford region was carried out to assess the level of clinician awareness and the uniformity of current guidelines between hospitals.

METHODS

A postal questionnaire was designed for asking information on various aspects of perioperative management of MRSA patients and was sent to each hospital.

RESULTS

Responses were obtained from nine of 10 hospitals in the region. The average response rate for each hospital was 75%, and the overall individual response rate was 67.5% (27/40). Seventy-eight per cent of respondents knew that there was a pre-admission screening policy. Fifteen per cent were unaware of any MRSA policy. Forty-four per cent indicated that teicoplanin was used for prophylaxis in implant surgery whilst 44% used vancomycin. Eighteen per cent believed that cefuroxime was used for prophylaxis. Forty-eight per cent of hospitals had an MRSA-free zone for orthopaedic patients.

CONCLUSION

This study indicates a lack of uniformity in the perioperative management of MRSA-positive patients in the region and a lack of awareness of both MRSA guidelines and their implementation. Uniformity of MRSA guidelines is necessary to allow better clinician awareness and compliance, especially in surgical trainees who are travelling between different training hospitals in the region. Implementation of such a policy with re-audit of subsequent awareness and compliance is proposed.

Snowdome, skiers and boarders: accident and emergency experience

A prospective case series was compiled of all people presenting to the accident and emergency department with an injury caused by snowboarding or skiing, during the first year of opening of the Milton Keynes snowdome. The aim was to analyse the types of injuries associated with recreational snowboarding and to compare these with the injuries seen in skiing. Of the snowboarders, 23 (86%) were males, and the mean age was 24 years. Of the skiers, 13 (81%) were males, and the mean age was 34 years. Forty-three injuries required orthopaedic review, and 12 were admitted for further management. Significant differences were noted between the patterns of injuries in snowboarding and skiing. The snowboarders had a higher incidence of upper limb injuries (96 vs. 62%) and a lower incidence of lower limb injuries (4 vs. 38%) compared to the skiers. This study demonstrates that the opening of a leisure facility has a significant impact on the local accident and emergency department. Snowboarding is associated with a unique pattern of injuries, the knowledge of which should influence education and accident prevention.

The value of detection of normal ovarian tissue (the 'ovarian crescent sign') in the differential diagnosis of adnexal masses

OBJECTIVE

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions.

METHODS

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.

RESULTS

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.

CONCLUSION

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

The impact of implementing the Ottawa ankle rules on ankle radiography requests in A&E

This audit was set up to quantify the effect of implementing the Ottawa ankle rules in a district general hospital that relies on both medical and nursing radiography requests. Data were collected prospectively on 207 patients who presented with an acute ankle injury between August 2001 and February 2002. The department's activity was recorded before and after a period of teaching on the Ottawa ankle rules. Before teaching, 71% of patients with an acute ankle injury were sent for radiography; teaching reduced this figure to 56% (p < 0.05). Auditing the activity of our department enabled us to observe a significant decrease in the number of patients sent for ankle radiography following acute ankle injury. This correlates well with research in other settings. The difficulties of rationalising radiology investigations are discussed.

Malignant ascites: new concepts in pathophysiology, diagnosis, and management

Malignant ascites is a manifestation of advanced malignant disease that is associated with significant morbidity. Mainstays of treatment include diuretics and recurrent large volume paracentesis. Although lymphatic obstruction has been considered the major pathophysiologic mechanism behind its formation, recent evidence suggests that immune modulators, vascular permeability factors, and metalloproteinases are contributing significantly to the process. These new observations offer the opportunity for development of new, more targeted therapies for the treatment of malignant ascites. This article uses a clinical case to highlight the problem, then reviews these new concepts in the pathophysiology of malignant ascites formation. The diagnosis and management of this challenging medical problem are subsequently discussed, with emphasis on how these new pathophysiologic insights are being applied to the development of novel therapies that may soon change how we manage this troubling clinical condition.

Insertion of Temporary Dialysis Catheters with the Aid of Real-time Ultrasound

Central venous catheters are widely used for both temporary and long-term angioaccess for hemodialysis. Insertion of these catheters is commonly performed using anatomic landmarks to guide vessel cannulation. Using traditional landmark-techniques, internal jugular venous catheter insertion is successful 82-88% of the time, with successful first-attempt cannulation of only 35-38%. Variations in anatomic relationships between the vein and surrounding structures may contribute to difficulty in venous cannulation using these traditional techniques. Real-time ultrasound guidance permits direct visualization of the target vein during catheter placement and is associated with increased successful cannulation (78-83% on first pass; 97-100% overall), a decreased number of attempts and a decreased complication rate. For this reason, we believe that real-time ultrasound-guided catheter insertion is superior to the traditional anatomic-landmark techniques and is emerging as the new standard of care.