The Exeter Activity Unlimited statement on physical activity and exercise for cystic fibrosis: methodology and results of an international, multidisciplinary, evidence-driven expert consensus

Background

The roles of physical activity (PA) and exercise within the management of cystic fibrosis (CF) are recognised by their inclusion in numerous standards of care and treatment guidelines. However, information is brief, and both PA and exercise as multi-faceted behaviours require extensive stakeholder input when developing and promoting such guidelines.

Method

On 30^th June and 1^st July 2021, 39 stakeholders from 11 countries, including researchers, healthcare professionals and patients participated in a virtual conference to agree an evidence-based and informed expert consensus about PA and exercise for people with CF. This consensus presents the agreement across six themes: (i) patient and system centred outcomes, (ii) health benefits, iii) measurement, (iv) prescription, (v) clinical considerations, and (vi) future directions. The consensus was achieved by a stepwise process, involving: (i) written evidence-based synopses; (ii) peer critique of synopses; (iii) oral presentation to consensus group and peer challenge of revised synopses; and (iv) anonymous voting on final proposed synopses for adoption to the consensus statement.

Results

The final consensus document includes 24 statements which surpassed the consensus threshold (>80% agreement) out of 30 proposed statements.

Conclusion

This consensus can be used to support health promotion by relevant stakeholders for people with CF.

Subjective Cognitive Decline in a Registry Sample: Relation to Psychiatric History, Loneliness, and Personality

BACKGROUND

With the increasing focus on prevention of Alzheimer's disease, there is need for characterization of preclinical populations. Local participant registries offer an opportunity to facilitate research engagement via remote data collection, inform recruitment, and characterize preclinical samples, including individuals with subjective cognitive decline.

OBJECTIVES

We sought to characterize subjective cognitive decline in a registry sample, as related to psychiatric history and related variables, including personality and loneliness, quality of life, and factors related to dementia risk (e.g., family history of dementia).

DESIGN, SETTING, PARTICIPANTS

Participants were 366 individuals (mean age=67.2 (range 50-88), 65% female, 94% white, 97% non-Hispanic or Latino, 82% with at least a bachelor's degree) with no reported history of mild cognitive impairment or dementia. All participants had expressed interest in research, primarily via community outreach events and prior research involvement. Data was collected via electronic surveys, distributed using REDCap. Electronic questionnaires included questions on demographic variables, subjective cognitive decline, quality of life, loneliness, and personality.

RESULTS

There was a high prevalence of risk factors for dementia in the registry sample (68% with family history of dementia, 31% with subjective cognitive decline). Subjective cognitive decline was more common in women and associated with history of depression, but not with family history of dementia. Subjective cognitive decline was also associated with lower conscientiousness and lower emotional stability, as well as higher loneliness and lower quality of life. Among participants who endorsed a psychiatric history, most reported onset more than 10 years prior, rather than within the last 10 years.

CONCLUSIONS

Subjective cognitive decline in a registry sample may be more strongly associated with longstanding psychiatric and personality variables, rather than family history of dementia, adding to the literature on characterization of subjective cognitive decline across different settings. These findings highlight the acceptability of remote data collection and the potential of registries to inform recruitment by characterizing registrants, which may help to stratify dementia risk and match participants to eligible trials.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020

OBJECTIVES

Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient.

METHODS

I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome.

INCLUSION CRITERIA

adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure).

RESULTS

I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation.

CONCLUSIONS

Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

First Report of Boxwood Blight Caused by Calonectria pseudonaviculata in Delaware, Maryland, New Jersey, and New York

Boxwood (Buxus spp.) are commercially important evergreen ornamental plants with an annual market value of over $103 million in the United States. The recent U.S. incursion of boxwood blight disease caused by the fungus Calonectria pseudonaviculata (syn. Cylindrocladium pseudonaviculatum, Cy. buxicola) threatens the health and productivity of boxwood in both landscape plantings and nurseries. The first confirmed U.S. reports of the disease were made from Connecticut and North Carolina in November 2011 (2,4), followed by diagnoses in 10 additional states during 2012 and 2013. By August 2013, symptoms consistent with boxwood blight had been observed from B. sempervirens in Delaware, Maryland, New Jersey, and southeastern New York. Affected plants showed rapid onset of disease symptoms: dark brown to black spots or diffuse dark areas on leaves, followed by defoliation. Narrow, elongate black cankers also formed on current season shoots. Symptomatic stems and leaves were placed in petri dishes with moistened filter paper at 22°C for 3 days under continuous light. Conidiophores were excised, then placed on potato dextrose agar amended with streptomycin and neomycin (0.3 g/l). Resultant colonies showed dark brown pigmentation at the colony center surrounded by tan to reddish brown rings with white mycelia at the advancing edge. Conidia (n = 30 per isolate) were hyaline, cylindrical, rounded at both ends, with a single septum (45 to 76 × 4 to 6 μm; avg. 63 × 5 μm). Conidiophores (n = 20 per isolate) comprised a stipe, a hyaline septate stipe extension (length 119 to 192 μm; avg. 150 μm) and a terminal ellipsoidal vesicle (diameter 4 to 10 μm; avg. 7 μm). Based on morphological characteristics, the causal agent was identified as C. pseudonaviculata (1,4). Voucher specimens were deposited in the U.S. National Fungus Collections (BPI 892698 to 701). To verify morphological diagnosis, genomic DNA was extracted from fungal biomass grown in liquid cultures of yeast extract peptone dextrose media. A portion of the β-tubulin gene (TUB2) was PCR amplified and sequenced bi-directionally using primers Bta/Bt2b (3). BLASTn searches of NCBI GenBank databases using the TUB2 sequences (Accession Nos. KF785808 to 11) demonstrated 96 to 100% sequence identity with other C. pseudonaviculata isolates. To confirm pathogenicity, 5-month-old B. sempervirens and B. microphylla seedlings were spray-inoculated with a spore suspension of 1 × 10⁴ conidia/ml. One isolate from each state was independently tested with four replicates each. Non-inoculated water-sprayed plants served as negative controls. Plants were maintained in growth chambers at 22°C under constant light. Blight symptoms developed 4 to 5 days post inoculation. C. pseudonaviculata was re-isolated from inoculated plants; no symptoms or signs were observed from control plants. To our knowledge, this is the first report of C. pseudonaviculata in the states of Delaware, Maryland, New Jersey, and New York. This report demonstrates that C. pseudonaviculata is now widespread across the United States eastern seaboard, and represents a substantial threat to boxwood plants in North American landscapes and nurseries. References: (1) P. Crous et al. Sydowia 54:23, 2002. (2) D. F. Farr and A. Y. Rossman. Fungal Databases, USDA-ARS. Retrieved from http://nt.ars-grin.gov/fungaldatabases , 30 August 2013. (3) N. L. Glass and G. C. Donaldson. Appl. Environ. Microbiol. 61:1323, 1995. (4) K. L. Ivors et al. Plant Dis. 96:1070, 2012.

The Canadian Orthopaedic Trauma Society

The Canadian Orthopaedic Trauma Society was started in an endeavour to answer the difficult problem of obtaining enough patients to perform top-quality research into fractures. By maintaining a high standard, including randomised study design, inclusivity, open discussion among surgeons and excellent long-term follow-up, this group has become a leader in the orthopaedic research community. This annotation describes the short history, important components and spirit necessary to build a research community or team which will function well despite the difficult research environment facing individual surgeons.

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

OBJECTIVE

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

DESIGN

Prospective Cohort.

SETTING

Level I Trauma Centre.

PATIENTS/PARTICIPANTS

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

INTERVENTION

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

MAIN OUTCOME MEASURE(S)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >108.

RESULTS

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.08 with a mean difference of 16.28(p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >108 from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.38 with a mean difference of 11.58 (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >108 from the uninjured limb.

CONCLUSIONS

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation.The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.

First Report of Brown Ring Patch Caused by Waitea circinata var. circinata on Poa annua and Agrostis stolonifera in New Jersey

Waitea circinata var. circinata was first reported as the causal agent of brown ring patch on annual bluegrass (Poa annua L.) in the United States in 2007 (2). In early April to mid-June of 2009, circular to irregularly shaped yellow rings resembling symptoms of this disease were observed on an annual bluegrass putting green at Rutgers University in North Brunswick, NJ. Severely infected foliage eventually turned brown as the disease progressed. During the same time period, similar disease symptoms were observed on creeping bentgrass (Agrostis stolonifera L.) from a golf course in Bedminster Township, NJ. The disease reappeared in both locations in April of 2010. Five additional samples with similar symptoms on creeping bentgrass and annual bluegrass were received at Rutgers Diagnostic Laboratory from Paramus, Madison, Allamuchy, and Farmingdale, NJ between late April and early May of 2010. Portions of diseased leaf and sheath tissue that displayed symptoms of the disease were disinfested for 1 min in 0.5% NaOCl, rinsed with sterile distilled water, and plated on potato dextrose agar (PDA) amended with 50 mg/liter of streptomycin sulfate. At the first sign of fungal growth, single hyphal tips were transferred to PDA. After 1 week at 25°C, white-to-orange mycelial colonies formed in culture and eventually turned brown with age. Minute sclerotia (≤3 mm), which followed the same color development pattern, formed within 10 days. These features are consistent with those described of W. circinata var. circinata (2,3). The internal transcribed spacer (ITS) region of the ribosomal RNA gene was amplified using primer pair ITS1/ITS4 and sequenced with ITS4 (GenBank Accession Nos. HQ166065 to HQ166071). BLASTn analysis of the ITS sequences showed a 99 to 100% similarity to W. circinata var. circinata sequences deposited in GenBank (1,2). Pathogenicity tests were conducted in 2010 using 6-week-old creeping bentgrass seedlings cv. Declaration inoculated with colonized oat grain that had been autoclaved and then infested with the Bedminster Township isolate. Eight colonized oat grains were uniformly spread around the crowns of seedlings grown in 10-cm-diameter pots. Control plants were treated with autoclaved grain. Plants were incubated at 25°C and high humidity maintained by misting the plants three times per day. Within 3 days postinoculation, foliage near infested grain turned chlorotic. All foliage in pots became completely blighted and spherical orange-brown sclerotia were observed on leaf sheaths by the eighth day. W. circinata var. circinata was consistently reisolated from inoculated plants (as confirmed by isolate morphology and ITS sequencing) but not from control plants. The ITS sequence data, morphological characters of the isolates, and pathogenicity tests demonstrate that W. circinata var. circinata is present in New Jersey. To our knowledge, this is the first report of W. circinata var. circinata infecting turfgrass in New Jersey. References: (1) C. M. Chen et al. Plant Dis. 93:906, 2009. (2) K. A. de la Cerda et al. Plant Dis. 91:791, 2007. (3) T. Toda et al. Plant Dis. 89:536, 2005.

Distinguishing recurrent primary brain tumor from radiation injury: a preliminary study using a susceptibility-weighted MR imaging-guided apparent diffusion coefficient analysis strategy

BACKGROUND AND PURPOSE

The accurate delineation of tumor recurrence presents a significant problem in neuro-oncology. Our aim was to improve the identification of brain tumor recurrence from chemoradiation injury by using CE-SWI, a technique that provides improved visualization of the heterogeneous patterns of brain tumor pathology, to guide the analysis of ADC measures within the peritumoral territory.

MATERIALS AND METHODS

Seventeen patients who were being treated for high-grade glial neoplasms took part in the study. All patients presented with new enhancing lesions on follow-up CE-T1. Recurrence or chemoradiation injury was confirmed from either histologic analysis or extensive clinical follow-up. Regions of enhancement on registered CE-SWI and CE-T1 images were extracted in a semiautomated fashion and transferred to co-registered ADC maps. Significant differences in ADC measures defined within the enhancement volumes on serial MR images were analyzed by using a nonparametric Kolmogorov-Smirnov approach and correlated with clinical follow-up diagnoses.

RESULTS

Analysis of the serial data revealed that patients with a diagnosis of tumor recurrence had significantly reduced ADC measures within the enhancement volume delineated on CE-SWI. In contrast, patients with SD had significantly elevated ADC within the CE-SWI enhancement volume.

CONCLUSIONS

The findings of an increase in enhancement volume delineated on serial CE-SWI maps, along with a concomitant reduction in ADC within this volume for patients with recurrent tumor, provide support for such an approach to be used to assist in follow-up patient management strategies.

Competencies for a Canadian orthopaedic surgery core curriculum

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and sds were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are 'driven' by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.

Prophylaxis of deep-vein thrombosis in fractures below the knee: a prospective randomised controlled trial

The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks. A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not. The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.

Quantifying the amount of padding improves the comfort and function of a fibreglass below-elbow cast

AIM

To determine the quantity of cotton underpadding needed for a comfortable, functional, below-elbow fibreglass cast.

METHODS

In this randomised, prospective, crossover, clinical trial, 45 people with minimally displaced distal radial fractures were enrolled to randomly receive, 14 days after injury, a fibreglass below-elbow cast with either two or four layers of cotton underpadding. The characteristics of the recipients were recorded. After 2 weeks of immobilisation, participants completed a numerical survey evaluating parameters of comfort and underwent clinical and radiographic assessment. They then crossed over to receive the other fibreglass cast design, the process was repeated, and they indicated their cast preference, if any.

RESULTS

Of 37 people who completed the study, 20 preferred the two-layer model, 13 the four-layer model and 4 had no preference. No significant trend for one design over the other was shown (p=0.1), nor any statistical association between preference and participant characteristics or the order in which cast models were received.

CONCLUSIONS

Participants did state a preference, but this was not related to recipient characteristics. Neither cast design was significantly the more comfortable; and both models were safe and functionally satisfactory.

Usefulness of susceptibility-weighted imaging for voxel placement in MR spectroscopy

MR spectroscopy is used to provide in vivo biochemical information about cerebral metabolites. Magnetic field homogeneity secondary to anatomic interfaces, hemorrhage, or necrosis may lead to suboptimal MR spectroscopy. Susceptibility-weighted imaging (SWI) can identify field inhomogeneity and could be used to guide MR spectroscopy voxel placement, leading to higher-quality MR spectroscopy examinations.

One hundred million years of chemical warfare by insects

An important defensive strategy among animals is the use of chemical compounds with toxic or irritating properties. In this paper, we report the discovery of an Early Cretaceous soldier beetle (Coleoptera: Cantharidae) in Burmese amber that seemingly employed a chemical defense response against a potential predator. Six pairs of cuticular vesicles with associated gland reservoirs were extruded from the insect's abdomen, and a secretion released from one of these covers a portion of the antenna of a second insect species, considered to be the perpetrator of the response. This is the earliest fossil record of a putative chemical defense response and suggests that chemical defense mechanisms in beetles have been in existence for at least 100 Ma.

1. Communication skills training in orthopaedics

Communication skills have been identified as a key component of medical education by the CanMEDS Project. The objectives of this study were to identify the perceived key components of communication skills from the perspectives of both orthopaedic residents and their program directors, and to understand how these skills are currently taught. This study utilized a mixed methods design. Quantitative data was collected using a 30-item questionnaire, which was distributed to all Canadian orthopaedic residents. Qualitative data was collected through focus groups with orthopaedic residents and semi-structured interviews with orthopaedic program directors. One hundred and nineteen out of three hundred and twenty-five questionnaires were completed (response rate = 37%), twelve residents participated in two focus groups, and 9/16 program directors from across the country were interviewed. The questionnaire reliability had an internal consistency of Cronbach’s alpha = 0.72. An ANOVA of the questionnaire data showed gender and International vs. Canadian medical graduate status to be independent variables to several item responses (P < 0.01). The factor analysis produced a five-factor model accounting for 50% of the variance. Both program directors and residents identified communication skills as being the accurate and appropriate use of language (ie, content skills), not how the communication was presented (ie, process skills). Perceived barriers to communication included time constraints and the need to adapt to the many personalities and types of people encountered daily in the hospital. Residents lack explicit communication skill training, but value developing communication skills in the clinical environment through experiential learning and role modeling. Resident education should focus on developing residents’ process skills in communication. Care should be taken to avoid large-group didactic teaching sessions, which are perceived as ineffective.

Rotational malalignment of the tibia following reamed intramedullary nail fixation

OBJECTIVE

To determine the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography and to determine the repeatability of computed tomography measurement in the assessment of rotational malreduction.

DESIGN

Prospective cohort.

SETTINGS

Level 1 trauma center.

PARTICIPANTS

Twenty-five consecutive patients with 25 tibial shaft fractures.

INTERVENTION

All patients were treated with reamed intramedullary nailing. Appropriate radiographs and a postoperative lower extremity computed tomography scan were obtained for each patient who consented to the study.

MAIN OUTCOME MEASURE

Rotational alignment of affected tibia as compared to a version of the normal contralateral limb. Malrotation was defined as an internal/external rotation deformity greater than 10degrees.

RESULTS

Malrotation, comparing the fractured limb to normal limb, was determined using a similar measurement method previously described in the literature. Two patients declined inclusion, and in one case, the computed tomography was not acceptable for analysis. Malrotation, comparing the fractured limb to the normal limb, was determined using the measurements from axial computed tomography images. Results revealed a mean absolute rotational difference of 6.7degrees (SD +/-6.3degrees). Rotational malreduction ranged from 15degrees of internal rotation to 22degrees of external rotation. Five of the 22 tibia (22%) were malrotated greater than 10degrees. A larger degree of deformity was seen with certain injury patterns. The intraobserver and interobserver repeatability testing revealed a mean absolute difference between paired malrotation calculations of 3.4degrees and 3.9degrees, respectively, and a repeatability coefficient of 8degrees for both.

CONCLUSION

Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.

Can the confidence in long range atmospheric transport models be increased? The pan-european experience of ensemble

Is atmospheric dispersion forecasting an important asset of the early-phase nuclear emergency response management? Is there a 'perfect atmospheric dispersion model'? Is there a way to make the results of dispersion models more reliable and trustworthy? While seeking to answer these questions the multi-model ensemble dispersion forecast system ENSEMBLE will be presented.

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management

OBJECTIVE

To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF).

DESIGN

Prospective, randomized, multicenter study.

SETTING

Four level I trauma centers.

PATIENTS

The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998.

INTERVENTIONS

Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus.

MAIN OUTCOME MEASUREMENTS

Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36).

RESULTS

There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery).

CONCLUSION

Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

Assessment of osteoporosis using standard radiographs of the wrist

BACKGROUND

This study evaluated the ability of the orthopaedic surgeon to radiographically assess bone density in the wrist with sufficient accuracy to determine which patients require treatment for osteoporosis.

METHODS

Thirty-eight patients with unilateral distal radius fractures, 30 of whom were female, were included in this study. The mean age was 55 years (range 45 to 82). Standard radiographs of the fractured and normal wrists were taken. Dual energy x-ray absorptiometry was performed on the normal distal radius of all patients within 1 week of their injury. The radiographs were viewed in blinded randomized fashion on two separate occasions by three orthopaedic surgeons and once by a fourth. The participants were required to determine the presence of osteoporosis. Visual analog scales (VAS) were used to evaluate (1) porosity, (2) cortical thickness, (3) trabecular thickness, and (4) the number of trabeculae in the ultradistal radius.

RESULTS

Intraobserver agreement assessing osteoporosis averaged 81% (kappa of 0.5393). VAS assessment was unreliable for all four parameters. Radiographic determination of osteoporosis had a specificity of 61% and a sensitivity of 61% using x-rays of the uninjured wrist.

CONCLUSION

We conclude that orthopaedic surgeons cannot predict with sufficient accuracy using plain x-rays whether a patient is significantly osteoporotic.

Alterations of the X-linked lymphoproliferative disease gene SH2D1A in common variable immunodeficiency syndrome

X-linked lymphoproliferative (XLP) disease is a primary immunodeficiency caused by a defect in the SH2D1A gene. At least 3 major manifestations characterize its clinical presentation: fatal infectious mononucleosis (FIM), lymphomas, and immunoglobulin deficiencies. Common variable immunodeficiency (CVID) is a syndrome characterized by immunoglobulin deficiency leading to susceptibility to infection. In some patients with CVID, a defective btk or CD40-L gene has been found, but most often there is no clearly identified etiology. Here, 2 unrelated families in whom male members were affected by CVID were examined for a defect in the XLP gene. In one family previously reported in the literature as having progressive immunoglobulin deficiencies, 3 brothers were examined for recurrent respiratory infections, whereas female family members showed only elevated serum immunoglobulin A levels. A grandson of one of the brothers died of a severe Aspergillus infection secondary to progressive immunoglobulin deficiency, FIM, aplastic anemia, and B-cell lymphoma. In the second family, 2 brothers had B lymphocytopenia and immunoglobulin deficiencies. X-linked agammaglobulinemia syndrome was excluded genetically, and they were classified as having CVID. The occurrence of FIM in a male cousin of the brothers led to the XLP diagnosis. Because the SH2D1A gene was found altered in both families, these findings indicate that XLP must be considered when more than one male patient with CVID is encountered in the same family, and SH2D1A must be analyzed in all male patients with CVID. Moreover, these data link defects in the SH2D1A gene to abnormal B-lymphocyte development and to dysgammaglobulinemia in female members of families with XLP disease.

Age, gender, work capability, and worker's compensation in patients with displaced intraarticular calcaneal fractures

OBJECTIVES

To determine which demographic variables are linked with outcome in displaced intraarticular calcaneal fractures. The variables studied were age, gender, work capability, Workers' Compensation Board (WCB) support, and injury type.

DESIGN

A prospective cohort study with a minimum of two years of follow-up.

SETTING

A university-affiliated Level I trauma hospital.

PATIENTS

One hundred sixty-nine patients who required treatment for displaced intraarticular calcaneal fractures treated by a single surgeon. To be included in the study, patients had to be aged between fifteen and sixty-five years at the time of the injury, have closed injuries, and have posterior facet displacement greater than two millimeters.

INTERVENTION

Patients were treated nonoperatively or operatively, using a lateral approach to the calcaneus.

MAIN OUTCOME MEASUREMENTS

Outcome was measured by return of patients to full-time work, change in work capability after treatment, the SF-36 health survey, and visual analog scales.

RESULTS

Male gender, medium and heavy labor, presence of WCB support, and presence of bilateral intraarticular fractures all proved to be associated with a poorer prognosis. Female patients did well when treated nonoperatively and operatively, whereas male patients always were less able to return to work at the same level as before the injury. Operatively treated patients returned to work quicker (average, eighty-seven days).

CONCLUSIONS

Males, multiply injured patients, and heavy laborers may have better outcomes with operative treatment, whereas females and non-WCB patients may do better with nonoperative treatment.

Imiquimod therapy for molluscum contagiosum

BACKGROUND

Molluscum contagiosum virus (MCV) is a large double-stranded DNA virus that is a member of the family Poxviridae, and which has a worldwide distribution. As with other poxviruses, MCV does not appear to develop latency but evades the immune system through the production of viral specific proteins.

OBJECTIVE

To evaluate the therapeutic efficacy of imiquimod 5% cream for MCV.

METHODS

Thirteen children >5 and <10 years old, 19 immune-competent adults and four adults with advanced, but stable HIV-1 disease with >10 MCV lesions were treated with topical 5% imiquimod cream three times weekly for up to 16 weeks.

RESULTS

Fourteen of 19 immune-competent adults, four of four adults with HIV-1 disease, and six of 13 children had resolution of their MCV lesions in <16 weeks of imiquimod therapy. Children tended to have more pruritus and inflammatory reactions with imiquimod, although most treated lesions appeared to respond. The development of new MCV lesions resulted in a lower overall resolution of the lesions in children. Imiquimod appeared to be the most efficacious in patients with HIV-1 disease and in the genital area in immune-competent adults.

CONCLUSION

Although topical imiquimod appears to have some efficacy in the therapy of MCV, in children the pruritus correlated relatively well with the development of new lesions. In adults, areas that would be expected to have better penetration appeared to respond more consistently. Although the HIV-1-positive patients had the largest clinical lesions at the onset of therapy, as a group they had the best overall response to therapy.

Lamivudine (3TC)-induced contact dermatitis

The nucleoside analogue lamivudine (3TC) is commonly used in multidrug therapy of human immunodeficiency virus-1 disease because it not only potentiates the antiviral effects of other reverse transcriptase inhibitors, but it is also relatively nontoxic. We present a patient who developed a contact dermatitis to lamivudine after prolonged exposure.

Monitoring Diffuse Impacts: Australian Tourism Developments

/ The scientific quality of monitoring for diffuse environmental impacts has rarely been quantified. This paper presents an analysis of all formal environmental monitoring programs for Australian tourism developments over a 15-year period from 1980 to 1995. The tourism sector provides a good test bed for this study because tourism developments are (1) often adjacent to or even within conservation reserves and other relatively undisturbed natural environments, and (2) often clustered, with resulting cumulative impacts that require detection at an early stage. Here we analyze the precision and reliability with which monitoring programs as actually implemented can detect diffuse environmental impacts against natural variation. Of 175 Australian tourism developments subject to EIA from 1980 to 1993 inclusive, only 13 were subject to formal monitoring. Only 44 individual parameters, in total, were monitored for all these developments together. No baseline monitoring was conducted for nine of the 44 parameters. For the remaining 35, only one was monitored for a full year. Before, after, control, impact, paired sampling (BACIP) monitoring designs were used for 24 of the 44 parameters, and power analysis in 10. The scientific quality of monitoring was significantly better for developments subject to control by the Great Barrier Reef Marine Park Authority (GBRMPA). The key factor appears to be the way in which GBRMPA uses external referees and manages external consultants. The GBRMPA model merits wider adoption.