Defining blood gas analysis stability limits across five sample types

Accurate reporting of blood gas samples is dependent upon following proper preanalytical sample handling requirements though there is variation for sample acceptability criteria across institutions. We examined five common sample types (arterial, venous, umbilical arterial, umbilical venous and capillary) stored at either room temperature or on crushed ice in a time series (0, 15, 30, 45, 60, 90, 180, 240 min) and applied local regulatory and/or institutional allowable performance limits to determine the need for cold preservation and/or maximum stability time for pH, pO₂, pCO₂, glucose, lactate, sodium, potassium, chloride, and ionized calcium where applicable in each sample type. Although changes in sample pO₂ and/or lactate values were responsible, in part or in whole, for surpassing the allowable limits in nearly all sample types analyzed, this was not uniformly observed across sample types within the typical time limits that are referenced in literature. Furthermore, we demonstrated that cold preservation may not ubiquitously provide longer stability for blood gas specimens and this is dependent on the sample type and analyte in question. Nevertheless, these results demonstrate the known instability of pO₂ and lactate and suggest that it may be possible to simplify the monitoring of preanalytical conditions by first evaluating pO₂ and lactate in patient blood gas samples if applicable.

The effectiveness of a multidisciplinary hip fracture care model in improving the clinical outcome and the average cost of manpower

After the implementation of the multidisciplinary geriatric hip fracture clinical pathway in 2007, the hospital length of stay and the clinical outcomes improves. Moreover, the cost of manpower for each hip fracture decreases. It proves that this care model is cost-effective.

INTRODUCTION

The objective of this study is to compare the clinical outcomes and the cost of manpower before and after the implementation of the multidisciplinary geriatric hip fracture clinical pathway (GHFCP).

METHODS

The hip fracture data from 2006 was compared with the data of four consecutive years since 2008. The efficiency of the program is assessed using the hospital length of stay. The clinical outcomes include mortality rates and complication rates are compared. Cost of manpower was also analysed.

RESULTS

After the implementation of the GHFCP, the preoperative length of stay shortened significantly from 5.8 days in 2006 to 1.3 days in 2011. The total length of stay in both acute and rehabilitation hospitals were also shortened by 6.1 days and 14.2 days, respectively. The postoperative pneumonia rate also decreased from 1.25 to 0.25%. The short- and long-term mortalities also showed a general improvement. Despite allied health manpower was increased to meet the increased workload, the shortened length of stay accounted for a mark decrease in cost of manpower per hip fracture case.

CONCLUSION

This study proves that the GHFCP shortened the geriatric hip fracture patients' length of stay and improves the clinical outcomes. It is also cost-effective which proves better care is less costly.

Important tips and numbers on using the cortical step and diameter difference sign in assessing femoral rotation--should we abandon the technique?

Rotational malalignment during femoral nailing is common despite having various intraoperative assessment methods. The cortical step sign and diameter difference sign (CSSDDS) is commonly used because of convenience, yet it lack proper scientific scrutiny and is thought to be error prone. Using a software algorithm, cross-sectional dimensions were obtained from CT scans of 22 intact adult femurs at the proximal, mid and distal diaphysis. With multiple simulated scenarios the sensitivity of CSSDDS was comprehensively determined at all possible C-arm positions. At rotation, cortical width changed most significantly around the thick linea aspera and femoral diameter changed most significantly at the sagittal plane. At 15 degrees of rotation and with the linea aspera in view, CSSDDS thresholds of 0.3mm, 0.6mm and 1mm had sensitivities of 98.8%, 93.1% and 73.8%. With the linea aspera masked behind the femur and out of view, the sensitivities significantly deteriorated to 96.4%, 77.1% and 44.1% respectively. CSSDDS is sufficiently sensitive only when strict rules are followed. It is imperative that the operator position the image intensifier in lateral view under proper magnification so that steps of less than 0.6mm around the linea aspera may be appreciated.

Sliding hip screw versus sliding helical blade for intertrochanteric fractures

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation.

In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group.

Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation.

The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used.

Cite this article: Bone Joint J 2015;97-B:398–404.

[Delayed necrotizing fasciitis: a complication of stress incontinence surgery by suburethral sling]

We report a 50-year-old woman case with an extensive necrotizing fasciitis (NF). The NF appeared 10 years after a tension free vaginal tape procedure for urinary stress incontinence. Vital prognosis was engaged due to the initial sepsis severity. This kind of complication is rare and could be under estimated. NF usually appear soon after surgery, whatever within the year following implantation. Anyway, NF are always related to a vaginal erosion of the tape.

Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Are cervical and breast cancer screening programmes equitable? The case of women with intellectual and developmental disabilities

BACKGROUND

Effective cancer screening must be available for all eligible individuals without discrimination. Lower rates of cervical and breast cancer screening have been reported in certain groups compared with women from the general population, such as women with intellectual and developmental disabilities (IDD). Research on the factors explaining those observed differences is crucial to determine whether practices are unfair and could be improved. The aim of this population-based study was to describe cancer screening utilisation by women with IDD in Ontario, Canada compared with other women in Ontario. The specific objectives were (1) to estimate the rates of cervical and breast cancer screening among eligible women with IDD in Ontario; (2) to compare the rates of cervical and breast cancer screening between eligible women with and without IDD; and (3) to examine if any observed differences between women with and without IDD persist after factors such as age, socio-economic status, rurality and healthcare utilisation are accounted for.

METHOD

This study draws women with IDD from an entire population, and draws a randomly selected comparison group from the same population. It controls for important confounders in cancer screening within the limitations of the data sources. The study was conducted using health administrative databases and registries in Ontario, Canada. Two cohorts were created: a cohort of all women identified as having an IDD and a cohort consisting of a random sample of 20% of the women without IDD.

RESULTS

The proportion of women with IDD who are not screened for cervical cancer is nearly twice what it is in the women without IDD, and 1.5 times what it is for mammography.

CONCLUSIONS

Findings suggest that women with IDD experience inequities in their access to cancer screening. Public health interventions targeting this population should be implemented.

Folate-receptor 1 (FOLR1) protein is elevated in the serum of ovarian cancer patients

OBJECTIVES

Ovarian cancer is the most lethal gynecological malignancy in North America. Although survival rates are high when the disease is diagnosed at an early stage, this decreases exponentially in late-stage diagnoses. As such, there is a need for novel early detection biomarkers. Through an integrated approach to ovarian cancer biomarker discovery that combines proteomics with transcriptomics and bioinformatics, our laboratory has identified folate-receptor 1 (FOLR1) and Dickkopf-related protein 3 (Dkk-3) as putative biomarkers. The objective of this study was to measure the levels of FOLR1 and Dkk-3 in the serum of patients with ovarian cancer, benign gynecological conditions and healthy women.

DESIGN AND METHODS

FOLR1 and Dkk-3 were analyzed in serum of 100 ovarian cancer patients, 100 patients with benign gynecological conditions, and 100 healthy women using enzyme-linked immunosorbent assays (ELISAs). All specimens were analyzed in triplicate.

RESULTS

FOLR1 was significantly elevated in the serum of ovarian cancer patients compared to serum of both healthy controls (P<0.0001) and patients with benign gynecological conditions (P<0.0001). Furthermore, FOLR1 was strongly correlated with CA125 as both were elevated in the serous histotype and in late-stage disease. FOLR1 did not outperform CA125 in receiver operating characteristic curve analysis and there was no significant complementarity between the two markers. Dkk-3 was not significantly different between the three serum cohorts and was not correlated with CA125.

CONCLUSIONS

FOLR1 is a new biomarker for ovarian cancer which correlates closely with CA125. The role of FOLR1 in the pathogenesis of ovarian cancer warrants further investigation.

Folate-receptor 1 (FOLR1) protein is elevated in the serum of ovarian cancer patients

OBJECTIVES

Ovarian cancer is the most lethal gynecological malignancy in North America. Although survival rates are high when the disease is diagnosed at an early stage, this decreases exponentially in late-stage diagnoses. As such, there is a need for novel early detection biomarkers. Through an integrated approach to ovarian cancer biomarker discovery that combines proteomics with transcriptomics and bioinformatics, our laboratory has identified folate-receptor 1 (FOLR1) and Dickkopf-related protein 3 (Dkk-3) as putative biomarkers. The objective of this study was to measure the levels of FOLR1 and Dkk-3 in the serum of patients with ovarian cancer, benign gynecological conditions and healthy women.

DESIGN AND METHODS

FOLR1 and Dkk-3 were analyzed in serum of 100 ovarian cancer patients, 100 patients with benign gynecological conditions, and 100 healthy women using enzyme-linked immunosorbent assays (ELISAs). All specimens were analyzed in triplicate.

RESULTS

FOLR1 was significantly elevated in the serum of ovarian cancer patients compared to serum of both healthy controls (P<0.0001) and patients with benign gynecological conditions (P<0.0001). Furthermore, FOLR1 was strongly correlated with CA125 as both were elevated in the serous histotype and in late-stage disease. FOLR1 did not outperform CA125 in receiver operating characteristic curve analysis and there was no significant complementarity between the two markers. Dkk-3 was not significantly different between the three serum cohorts and was not correlated with CA125.

CONCLUSIONS

FOLR1 is a new biomarker for ovarian cancer which correlates closely with CA125. The role of FOLR1 in the pathogenesis of ovarian cancer warrants further investigation.

CUB and zona pellucida-like domain-containing protein 1 (CUZD1): a novel serological biomarker for ovarian cancer

OBJECTIVES

To measure the levels of serum CUB and zona pellucida-like domain-containing protein 1 (CUZD1) in patients with ovarian cancer (OvCa), benign gynecological conditions and healthy women and in a number of other cancer types (breast, colorectal, lung, prostate and testicular).

DESIGN AND METHODS

Serum CUZD1 levels were measured with a commercial enzyme-linked immunosorbent assay (ELISA). All specimens were analyzed in duplicate. Preliminary verification was performed in serum using 9 healthy women and 20 late stage (III-IV) OvCa patients. An independent cohort of serum samples was used to validate the verification results (18 late stage OvCa, 8 benign gynecological conditions and 8 healthy controls). The following specimens were used for the other cancer types of unknown stage-breast (n=11), colorectal (n=10), lung (n=10), prostate (n=15) and testicular (n=10).

RESULTS

Serum CUZD1 was significantly elevated in ovarian cancer patients (range 95-668 μg/L) as compared to healthy controls (range 0.7-2.5 μg/L). The independent cohort of OvCa samples confirmed the preliminary verification results. CUZD1 was also elevated in breast and lung cancer specimens and not in colorectal, prostate and testicular cancer specimens.

CONCLUSIONS

CUZD1 appears to be a highly promising novel serum biomarker for OvCa diagnosis. Its performance in the 2 independent cohorts examined, and in lung and breast cancer patients warrants further investigation.

Peri-operative management of anti-platelet agents and anti-thrombotic agents in geriatric patients undergoing semi-urgent hip fracture surgery

Hip fractures are common events in the geriatric population and are often associated with significant morbidity and mortality. Over the coming decades, the size of the greying population is forecast to increase and hence, the annual incidence of hip fracture is expected to rise substantially. Several studies have shown that hip fracture surgery performed within 24 to 48 h of hospitalisation significantly reduces mortality. Medical specialists including cardiologists are often involved in the care of these geriatric patients as most of them have comorbid conditions that must be managed concomitantly with their fracture. Cardiovascular and thromboembolic complications are among some of the commonest adverse events that could be experienced by these elderly patients during hospitalisation. We review in this article the current recommendations and controversies on the peri-operative management of anti-platelet agents and anti-thrombotic agents in geriatric patients undergoing semi-urgent hip fracture surgery.

Preoperative cardiac risk assessment in geriatric patients with hip fractures: an orthopedic surgeons' perspective

Hip fracture is one of the most common orthopedic conditions and is associated with significant morbidity and mortality. With a progressively aging population, the annual incidence of hip fracture is expected to increase substantially. Emerging evidence suggests that early surgery (<24 h) minimizes complications secondary to immobilization, including orthostatic pneumonia and venous thromboembolism. Delayed surgical repair (>48 h) has been consistently demonstrated to be associated with an increased risk of 30-day and 1-year mortality. Nonetheless, early surgery necessitates a shorter time for preoperative medical preparation, in particular cardiac assessment. Patients who undergo emergent orthopedic surgery are therefore at greater risk of perioperative cardiac events than those who undergo elective surgery. In addition, the prompt triage system for preoperative cardiac assessment not only identifies patients at high risk of perioperative cardiac complications but also reduces unnecessary cardiac consultations for low-risk patients. We review the current recommendations for preoperative cardiac assessment adapted for patients with hip fracture and describe our current triage system for preoperative cardiac consultation.

Geriatric hip fracture clinical pathway: the Hong Kong experience

Geriatric hip fracture is one of the commonest fractures in orthopaedic trauma. There is a trend of further increase in its incidence in the coming decades. Besides the development of techniques and implants to overcome the difficulties in fixation of osteoporosis bone, the general management of the hip fracture is also very challenging in terms of the preparation of the generally poorer pre-morbid state and complicate social problems associated with this group of patients. In order to cope with the increasing demand, our hospital started a geriatric hip fracture clinical pathway in 2007. The aim of this pathway is to provide better care for this group of patients through multidisciplinary approach. From year 2007 to 2009, we had managed 964 hip fracture patients. After the implementation of the pathway, the pre-operative and the total length of stay in acute hospital were shortened by over 5 days. Other clinical outcomes including surgical site infection, 30 days mortality and also incidence of pressure sore improved when compared to the data before the pathway. The rate of surgical site infection was 0.98%, and the 30 days mortality was 1.67% in 2009. The active participation of physiotherapists, occupational therapists as well as medical social workers also helped to formulate the discharge plan as early as the patient is admitted. In conclusion, a well-planned and executed clinical pathway for hip fracture can improve the clinical outcomes of the geriatric hip fractures.

Does timing of surgery matter in fragility hip fractures?

The effect of delay of surgery on the geriatric hip fractures has been a subject of interest in the past two decades. While the elderly patients will not tolerate long periods of immobilization, it is still unclear how soon these surgeries need to be performed. A review of existing literature was performed to examine the effect of timing of surgery on the different outcome parameters of these patients. Although there is conflicting evidence that early surgery would improve mortality, there is widespread evidence in the literature that other outcomes including morbidity, the incidence of pressure sores, and the length of hospital stay could be improved by shortening the waiting time of hip fracture surgery. We concluded that it is beneficial to the elderly patients to receive surgical treatment as an urgent procedure as soon as the body meets the basic anesthetic requirements.

Pre-operative pulmonary assessment for patients with hip fracture

Hip fracture is a common injury among the elderly. Although patients who receive hip fracture surgery carry the best functional recovery compared to other treatment modalities, the presence of postoperative pulmonary complications, such as atelectasis, pneumonia, and pulmonary thromboembolism, may contribute to increased length of hospital stay, perioperative morbidity, and mortality. This review aims to provide evidence-based recommendations for preoperative assessment and perioperative strategies to reduce the risk of pulmonary complications after hip fracture surgery. Clinical assessment and basic laboratory results are sufficient to stratify the risk of postoperative pulmonary complications. Well-documented risk factors for pulmonary complications include advanced age, poor general health status, current infections, pre-existing cardiopulmonary diseases, hypoalbuminemia, and impaired renal function. Apart from optimizing the patient's medical conditions, interventions such as lung expansion maneuvers and thromboprophylaxis have been proven to be effective in reducing the risk of pulmonary complications after hip fracture surgery.

[Radiation-induced breast angiosarcoma following breast-conserving therapy. Report of two cases]

Breast angiosarcoma is a rare but serious complication of radiotherapy. We report two cases of radiation-induced breast angiosarcoma in two patients having benefited from breast conserving surgery with radiation. We shall put emphasis on the etiopathogeny of these tumours and their clinical and therapeutic aspects.

[Ovarian remnant syndrome: diagnostic difficulties and management]

OBJECTIVES

The ovarian remnant syndrome is a rare condition after unilateral or bilateral oophorectomy, with or without a hysterectomy. This syndrome occurs when a fragment of ovarian tissue is left behind and becomes functional and cystic. The purpose of this study is to report the cases of patients treated surgically for an ovarian remnant syndrome during the last 10 years and to recall the diagnostic and therapeutic difficulties.

PATIENTS AND METHODS

A retrospective, observational study was carried out between 1997 and 2006. Seven patients were treated surgically for an ovarian remnant syndrome. Perioperative data analysis (history, surgical techniques, and postoperative follow-up) was carried out.

RESULTS

The mean age of the patients was 46 years (36-55). The number of previous abdominal surgical procedures ranged from 2 to 5. The syndrome appeared after a mean period of 4 years and 4 months (range 5 months-12 years) after oophorectomy. Among the 7 patients, 3 had had a previous hysterectomy. Pelvic pain was found in all cases. Gonadotropin-releasing hormones agonists were used in 1 patient without success. Aspiration was performed in 2 cases before surgical treatment. Two patients underwent a laparotomy in the first place. Laparoscopy was performed in 5 cases and laparoconversion was necessary in 1 case. Intraoperative difficulties and anatomic variations were found in all cases. Ureteral catheters were placed in 2 cases. Radiotherapy was performed in 1 patient who had a recurrent ovarian remnant.

DISCUSSION AND CONCLUSION

The ovarian remnant syndrome is a rare complication. Surgery, either by laparoscopy or by laparotomy, is the recommended treatment. These operations are often difficult and associated with a high risk of complications. Histologically, remnant ovarian tissue associated with hemorragic corpus luteum cysts is the most common finding. The prevention of the ovarian remnant syndrome is based on rigorous surgical treatment during the oophorectomy so as not to leave behind ovarian tissue.

[Tamoxifen in the adjuvant setting for breast cancer: Reflexions about the risk of uterine carcinosarcoma]

A descriptive analysis of available data on reported cases of uterine carcinosarcomas associated with tamoxifen therapy is undertaken. The role of aromatase inhibitors as alternative to tamoxifen therapy in the adjuvant setting of breast cancer is discussed. The eventual implications of the presumed association of uterine carcinosarcoma and tamoxifen therapy on the choice of the therapeutic agent in the adjuvant setting of hormone-sensitive breast cancer are discussed.

[Spontaneous rupture of the unscarred uterus during labor. Case report]

We report a case of spontaneous uterine rupture in a 19 year-old patient Gravida 1 para 2 with no past history of uterine surgery. The diagnosis of uterine rupture, evoked in the early post-partum in the presence of acute abdominal pain, collapsus and haemoperitoneum on ultrasonography, was confirmed by laparotomy. Treatment consisted in hysterorrhaphy. The etiopathogenesis, clinical and therapeutical aspects of spontaneous unscarred uterine ruptures are discussed throughout a literature review.

[Pure rhabdomyosarcoma of the uterine corpus: an exceptional tumor in postmenopausal women. Report on two cases]

Rhabdomyosarcoma (RMS) of the uterine corpus is rare in adult females. This tumor can be encountered in two distinct histopathological contexts: usually as a component of a malignant mixed mullerian tumor and exceptionally as a pure heterologous sarcoma. We report two cases of pure RMS of the uterine corpus occurring in postmenopausal women. The two patients suffered from vaginal bleeding and preoperative diagnosis was achieved in both cases. Both patients benefited from exploratory laparotomy, total hysterectomy and bilateral salpingo-oophorectomy. Both of them were free from the disease 15 months and 1 year respectively, after initial surgery. These two observations are worthy of publication because pure RMS of the uterine corpus is exceptional in postmenopausal women.

Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures

Nowadays, the use of minimally invasive plate osteosynthesis (MIPO) in the management of fracture of the distal tibia is common. The various advantages of the MIPO technique, namely, preserving blood supply and better bone healing, have been described extensively in the literature. However, this technique is not without complication. Among all the complications, infection is one of the commonest. In the last 3 years, we have performed 48 cases of MIPO in treating distal tibia fractures. Our study was to evaluate the clinical outcome of these cases, with special attention to the infection rate and our experience in managing these infection cases. Our results showed that the average time until the patient started to bear full weight was 9.4 weeks. The average time for bony union was 18.7 weeks. There were 7 cases of late infection among these 48 cases. The rate was 15%. The presence of late infection had no obvious effect on the time to bony union. Twenty-five patients (52%) had the implants removed and the most common reason was skin impingement by the implant. The clinical presentation and management of these late infections are discussed. In conclusion, MIPO fixation of distal tibia fractures using a metaphyseal locking plate is safe and efficient. However, complications such as late wound infection and impingement are relatively common. The overall clinical outcome is still good despite the presence of these complications.

[The diagnostic problem of uterine sarcomas: report on a case of carcinosarcoma mimicking a gastro-intestinal disease]

Uterine sarcomas are rare tumours with poor prognosis. The most common presenting symptoms are vaginal bleeding or pelvic pain. We present a case of uterine carcinosarcoma diagnosed retrospectively after surgical specimen analysis in a 69-year-old patient presenting gastro-intestinal complaints. At the time of diagnosis, the patient was in FIGO, stage IV.

[Primary non-Hodgkin lymphoma of the uterine corpus. Case report and review of the literature]

We report a case of primary nonHodgkin lymphoma (NHL) of the uterine corpus, diagnosed by endometrial biopsy, in a 60-year-old patient suffering from uterine bleeding. Pathological analysis had concluded to diffuse large B-cell lymphoma. Further staging had not revealed other nodal or extranodal localization (Ann Arbor stage IE) and there were no signs of recurrence during follow-up. Therefore, the diagnostic criteria for true primary NHL of the uterine corpus were met. This localization is extremely rare since only six cases have previously been published. The patient was successfully treated by an immunochemotherapy combining rituximab-CHOP and rituximab-VCAP. After 28 months of follow-up, she is free from the disease. A review of the literature regarding these exceptional tumors is undertaken.

Locking compression plate in the treatment of forearm fractures: a prospective study

PURPOSE

To evaluate the use of locking compression plates (LCPs) in diaphyseal forearm fractures.

METHODS

9 women and 23 men (mean age, 35; range, 12-70 years) with 45 forearm fractures were treated by open reduction and internal fixation with 3.5-mm stainless steel LCPs. All patients were followed up monthly until union; the mean duration being 20 months. Radiographic assessment was performed at 3, 6, 12, and 18 months. Clinical assessments regarding pain and function were undertaken at the final follow-up.

RESULTS

Two patients had delayed union but none had nonunion. There was no deep infection and only one superficial infection. Two refractures occurred after implant removal, both were of simple transverse type and at the sites of the original fractures. 33% of the fractures were reduced anatomically. 56% of the fractures healed with no or minimal callus formation and 44% with moderate callus formation. In total, 13% of the anatomically reduced fractures had moderate or abundant callus formation. 22 patients opted for removal of the implants (29 LCPs), after a mean of 16 (range, 9-21) months.

CONCLUSION

The LCP is an effective bridging device used for treating comminuted fractures, but for treating simple fractures its superiority over conventional plating is yet to be proven.

Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture

The management of fractures of the proximal shaft of the humerus has been evolving since the development of new techniques and new implants in recent years. It seems that this kind of fracture has an increasing incidence in the older, osteoporotic population. In the last 2 years, we have operated on 17 patients, with an average age of 65, who had proximal humeral shaft fractures treated by minimally invasive percutaneous osteosynthesis (MIPO) technique using the metaphyseal locking compression plate. Our study evaluated the surgical technique used and the outcome for these patients with regards to their range of movement and shoulder function. Our results showed that all the patients could achieve at least 140 masculine of shoulder abduction in the first 6 months after the operation, except for three patients who had shoulder impingement. These patients had an average Constant score of 76.8. All fractures had bony union at 6 months, except one, which was probably due to poor reduction in the initial operation. Another complication that we encountered was radial nerve neuropraxia. The ways to prevent these complications are discussed. In conclusion, MIPO fixation using the metaphyseal locking compression plate is a good option for the management of proximal humeral shaft fractures. It provides early functional recovery, but we had to pay special attention to some of the surgical details in order to minimise complications.

Nicolau syndrome following intramuscular diclofenac administration: a case report

Nicolau syndrome (livedoid dermatitis) is a rare adverse reaction of a still largely unidentified pathogenesis at the site of intramuscular drug injection. The typical presentation is pain around the injection site soon after injection, followed by erythema, livedoid patch, haemorrhagic patch, and finally necrosis of skin, subcutaneous fat, and muscle tissue. The phenomenon has been related to the administration of a variety of drugs, including non-steroidal anti-inflammatory drugs, corticosteroids, and penicillin. We report a case of Nicolau syndrome following an intramuscular injection of diclofenac. The large ulceration over the right buttock was positive for Pseudomonas aeruginosa, and histology revealed subcutaneous fat necrosis and non-specific inflammation with no evidence of malignancy or vasculitis. The lesion required multiple debridements and a partial-thickness skin graft. Subcutaneous injection, rather than intramuscular injection, was found to be a determining factor in this case. Clinicians must be cautious in the use of proper injection procedures, including appropriate needle length, in order to minimise complications.

Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate--a biomechanical study in a cadaveric model

The stability of palmar plate fixation using a locking compression T-plate was compared with that of a conventional palmar T-plate and a dorsal T-plate in a cadaveric model of an AO type C2 fracture of distal radius. The wrist axial load transmission through the radius was tested for each fixation. The results show that, under 100N axial load, the palmar locking compression T-plate restores stability comparable to that of the intact radius, and is superior to conventional palmar or dorsal T-plates.

Metal-on-metal versus polyethylene in hip arthroplasty: a randomized clinical trial

A prospective, randomized, blinded clinical trial was done to evaluate polyethylene versus metal bearing surfaces in total hip replacement. Forty-one patients were randomized to receive either a metal (23 patients) or a polyethylene (18 patients) insert. The femoral and acetabular components were identical with the acetabular insert the only variable. Patients were assessed preoperatively and postoperatively using radiographs, multiple outcome measures (Western Ontario MacMaster University Score, Harris hip score, Short Form-12), erythrocyte metal ion analysis (cobalt, chromium, titanium), and urine metal ion analysis (cobalt, chromium, titanium). Patients were followed up for a minimum of 2 years (mean 3.2 years; range, 2.2-3.9 years). There were no differences in radiographic outcomes or outcome measurement tools between patients. Patients receiving a metal-on-metal articulation had significantly elevated erythrocyte and urine metal ions compared with patients receiving a polyethylene insert. Patients who had metal-on-metal inserts had on average a 7.9-fold increase in erythrocyte cobalt, a 2.3-fold increase in erythrocyte chromium, a 1.7-fold increase in erythrocyte titanium, a 35.1-fold increase in urine cobalt, a 17.4-fold increase in urine chromium, and a 2.6-fold increase in urine titanium at 2 years followup. Patients receiving a polyethylene insert had no change in erythrocyte titanium, urine cobalt, or urine chromium and a 1.5-fold increase in erythrocyte cobalt, a 2.2-fold increase in erythrocyte chromium, and a 4.2-fold increase in urine titanium. Forty-one percent of patients receiving metal-on-metal articulations had increasing metal ion levels at the latest followup.

Cultural expectations of thinness in Chinese women

The present study examined the ideal woman's figure among Chinese people in Hong Kong over the past three decades by analyzing the data from the Miss Hong Kong Beauty Pageant from 1975-2000. Results indicate that Miss Hong Kong Pageant winners and Miss Photogenic winners have always been taller and thinner than average women in Hong Kong. The data also suggest that a curvaceous body shape with a narrow waist set against full hips appears to be an important component of feminine beauty among the Chinese. This ideal matches closely to what has been depicted in classical Chinese literature and challenges the commonly held belief that Chinese feminine beauty standards value plumpness.

Conservative treatment of intra-articular fractures of the distal radius--factors affecting functional outcome

One hundred and eleven intra-articular fractures of the distal radius in young adults that were conservatively treated were studied. At two years, 80% of fractures were rated as excellent or good by the modified Green and O'Brien scoring system. The rate of re-displacement within casts was 28%. Sixty five per cent of re-displaced fractures were treated with surgical fixation. Those re-displaced fractures treated with repeated manipulation had only 33% excellent or good result. Moreover, their initial alignment could not be preserved. Axial compression (>2 mm) and dorsal angulation (>15 degrees ) were directly related to worse functional outcome and diminished range of motion.

Testing a dual-process family model in understanding the development of eating pathology: a structural equation modeling analysis

OBJECTIVE

The present study tested a dual-process family model in understanding the relationships among dysfunctional family relationships, family preoccupation with weight and appearance, and body- and self-esteem problems in the development of eating and psychiatric symptoms.

METHOD

Subjects, 918 adolescent girls from eight high schools, completed measures assessing familial factors, body- and self-esteem problems, and eating and general psychiatric symptoms.

RESULTS

Structural equation analyses suggested that family environment contributed to the development of eating and psychiatric symptoms through two interrelated pathways. On one hand, family preoccupation with weight and appearance had direct effects on body dissatisfaction and eating symptoms. Body dissatisfaction had direct effects on self-esteem deficit and eating symptoms, and indirect effects mediated by self-esteem deficit on eating and psychiatric symptoms. On the other hand, general family dysfunction had direct effect on negative self-esteem, and indirect effects through negative self-esteem on eating and psychiatric symptoms.

DISCUSSION

Findings are discussed in relation to the possible mechanisms by which dysfunctional family relationships and family preoccupation with weight may predispose girls to eating pathology.

Issues and concerns associated with different risk models for eating disorders

OBJECTIVE

The present paper examines issues and concerns associated with different risk models in identifying individuals who may be vulnerable for eating disorders.

METHOD

Studies were located by computerized search and the authors' knowledge of the literature. For the purposes of this paper, different risk models are grouped according to three types of sample selection criteria: exposure to environmental pressures toward thinness, parental psychopathology, and intraindividual characteristics. Intraindividual characteristics were subdivided into biological and behavior vulnerability markers, and within the behavior risk approach, symptom and nonsymptom risk models were further identified.

RESULTS

Our literature review indicates that risk research on eating disorders is still in its formative years. More well-planned prospective risk studies are needed.

CONCLUSIONS

Among these risk models, the nonsymptom risk approach, which defines risk on the basis of nonsymptom vulnerability markers, represents one of the more promising avenues for future risk research and deserves further exploration.