The impact of elite endurance activity on cardiac remodelling in asians: an echocardiographic case control study

Background

Prolonged endurance training results in physiological changes to elite athletes' hearts. These changes include thickened left ventricular (LV) walls and dilated left and right ventricles that may overlap with those from pathological conditions such as hypertrophic cardiomyopathy, dilated cardiomyopathy and arrhythmogenic cardiomyopathy. While reference ranges for elite black and white athletes have been published to facilitate differentiation of physiology from pathology, data on Asian athletes remains scarce. With increasing Asian representation in international sport, it is important to ascertain the extent of physiological cardiac remodelling in Asian athletes.

Purpose

This study aimed to compare echocardiographic parameters of elite endurance athletes (EAs) and non-endurance controls and describe reference ranges in this population of Asian athletes.

Methods

Consecutive elite athletes engaging in endurance sport were identified from the Singapore Sports Cardiology Registry from January to October 2018. Controls were obtained from 3 sources: (a) skill-based athletes from the Singapore Sports Cardiology Registry, (b) healthy non-athletic volunteers from a national atrial fibrillation registry, and (c) healthy non-athletic volunteers from a national heart failure registry. All participants underwent resting two-dimensional, M-mode and Doppler transthoracic echocardiography and findings from EA were compared with controls.

Results

165 participants (55 EAs, 110 controls) were analysed (median age 29 years, male gender n=95; 58%, Chinese ethnicity n=55 for EAs; 100%) Baseline characteristics between both groups were comparable (Table 1). EAs had larger LV wall thickness (9.2 vs. 8.1 mm, p<0.001), LV cavity size (50.7 vs. 48.2 mm, p<0.001), LV mass index (98.4 vs. 73.8 g/m2, p<0.001), aortic root diameter at sinus of Valsalva (30.6 vs. 28.9 mm, p<0.01), right ventricular dimensions and biatrial volumes compared to controls (Table 2). Similar results were noted after indexing to body surface area. These associations also persisted after adjusting for age.

Conclusion(s)

Endurance activity in elite Singaporean Chinese athletes was associated with significant structural and functional cardiac remodeling compared to controls. Reference ranges for echocardiographic parameters in this population were described, allowing for more accuracy when differentiating physiology from pathology in Asian athletes.

Funding Acknowledgement

Type of funding sources: None.

The Effect of Cellulose Nanocrystals (CNC) on Isothermal Crystallization Kinetics of LLDPE and HDPE

Highly porous agglomerates of spray freeze dried cellulose nanocrystals (SFD-CNC) were prepared, starting with sonicated aqueous suspensions of spray-dried cellulose nanocrystals powder (SD-CNC). Subsequently, SFD-CNC together with the SD-CNC (used as a reference) were incorporated into LLDPE and HDPE via melt compounding in a batch mixer to produce nanocomposites containing 0.5 wt.° and 2 wt.° CNC. Differential scanning calorimetry (DSC) was used to study the thermal properties and the isothermal crystallization kinetics of the polyethylenes and the nanocomposites. Polarized light microscopy (PLM) was used to evaluate the growth kinetics and spherulitic structure of polyethylene in both the filled and unfilled polymers. Avrami crystallization kinetics models were employed to analyze the DSC results. It was observed that CNC acts as a heterogeneous nucleating agent in LLDPE nanocomposites, thus yielding nucleation controlled crystallization. On the other hand, in the HDPE systems (polymer and nanocomposites) heterogeneous nucleation was followed by 3-D growth. It was observed that CNC slightly hindered the formation of chain folding for the HDPE, similar to previous studies on the polypropylene and its nanocomposites. Spray freeze drying produced twice as many nucleation sites compared to spray dried samples and it enhanced the overall crystallization rate and the crystallinity.

Evidence flowers: An innovative, visual method of presenting "best evidence" summaries to health professional and lay audiences

BACKGROUND & AIMS

Barriers to dissemination and engagement with evidence pose a threat to implementing evidence-based medicine. Understanding, retention, and recall can be enhanced by visual presentation of information. The aim of this exploratory research was to develop and evaluate the accessibility and acceptability of visual summaries for presenting evidence syntheses with multiple exposures or outcomes to professional and lay audiences.

METHODS

"Evidence flowers" were developed as a visual method of presenting data from 4 case scenarios: 2 complex evidence syntheses with multiple outcomes, Cochrane reviews, and clinical guidelines. Petals of evidence flowers were coloured according to the GRADE evidence rating system to display key findings and recommendations from the evidence summaries. Application of evidence flowers was observed during stakeholder workshops. Evaluation and feedback were conducted via questionnaires and informal interviews.

RESULTS

Feedback from stakeholders on the evidence flowers collected from workshops, questionnaires, and interviews was encouraging and helpful for refining the design of the flowers. Comments were made on the content and design of the flowers, as well as the usability and potential for displaying different types of evidence.

CONCLUSIONS

Evidence flowers are a novel and visually stimulating method for presenting research evidence from evidence syntheses with multiple exposures or outcomes, Cochrane reviews, and clinical guidelines. To promote access and engagement with research evidence, evidence flowers may be used in conjunction with other evidence synthesis products, such as (lay) summaries, evidence inventories, rapid reviews, and clinical guidelines. Additional research on potential adaptations and applications of the evidence flowers may further bridge the gap between research evidence and clinical practice.

Knowledge of HPV/cervical cancer and acceptability of HPV self-sampling among women living with HIV: A scoping review

Cervical cancer rates are disproportionately high among women living with the human immunodeficiency virus (wlhiv). Cervical cancer is preventable through hpv screening, regular Pap tests, and early cancer detection. Evidence indicates that hpv and cervical cancer screening are suboptimal among wlhiv, who face a myriad of access barriers. Considering that screening is an effective first-line defense to cervical cancer, we conducted a scoping review with the aim of gaining a better understanding about: (1) the knowledge and perceptions of hpv and cervical cancer screening among wlhiv; and (2) the acceptability of self-sampling for hpv among wlhiv. We searched five electronic databases for peer-reviewed articles that were published in English within the last ten years, reported on studies with hiv-positive women who were aged 16 or older, and satisfied the topics of the review. A total of 621 articles were found. After accounting for duplicates and unmet criteria, 17 articles and 1 abstract, reporting on studies in the United States and Africa, were included in this review. The review highlighted that most wlhiv had inadequate knowledge of hpv transmission and cervical cancer prevention, which influenced their perceptions of risk and susceptibility. Screening barriers included misconceptions about Pap tests, fear of diagnosis of serious illness, perceived pain, embarrassment, bodily modesty, and limited access to female health care providers. This review also affirms that self-sampling is an acceptable and promising screening option for wlhiv. Implications for policy, research, and practice are discussed.

Total midgut volvulus in adults with intestinal malrotation. Report of eleven patients

OBJECTIVE

Total small-intestinal volvulus with malrotation (TSIVM) classically presents in the neonatal period; it occurs much less frequently in the adult and is often misdiagnosed. Prognosis is directly related to the degree and duration of intestinal ischemia. Our goal is to describe our experience with TSIVM in the adult, to identify any specific findings and to discuss its management.

METHOD

Eleven patients who had undergone surgery for TSIVM at three centers between 1992 and 2012 were included. Surgery was performed as an emergency for five patients and surgery was elective for six.

RESULTS

Mean follow-up was 63 months (range: 12-270). Six patients had had previous abdominal surgery. In nine cases, the diagnosis of TSIVM was made preoperatively, mainly by CT scan in eight cases. Seven patients had associated congenital failure of retroperitoneal fixation of the right colon and all of these underwent a Ladd procedure. The mortality rate was zero. Of the five patients who underwent emergency surgery, three required intestinal resections, one of whom developed a short bowel syndrome. The six patients who underwent surgery electively had no surgical complications.

CONCLUSION

TSIVM is a very unusual finding in adult patients. The diagnosis can be made by CT scan with IV and oral contrast, but it often comes to light only at the time of surgery, even though the patients have often had recurrent episodes of abdominal symptomatology that dated back to childhood. The Ladd procedure, consisting of division of Ladd's bands, widening of the mesentery, and incidental appendectomy, remains the standard surgical repair. Digestive surgeons who care for adults should be familiar with this procedure, and it should be performed, as often as possible, with the assistance of a pediatric surgeon.

Influences on the decision to use an osteoarthritis diagnosis in primary care: a cohort study with linked survey and electronic health record data

OBJECTIVE

Clinicians may record patients presenting with osteoarthritis (OA) symptoms with joint pain rather than an OA diagnosis. This may have implications for OA research studies and patient care. The objective was to assess whether older adults recorded with joint pain are similar to those with a recorded OA diagnosis.

METHOD

A study of adults aged ≥50 years in eight United Kingdom general practices, with electronic health records linked to survey data. Patients with a recorded regional OA diagnosis were compared to those with a recorded joint pain symptom on socio-demographics, risk factors, body region, pain severity, prescribed analgesia, and potential differential diagnoses. A sub-group was compared on radiographic knee OA.

RESULTS

Thirteen thousand eight hundred and thirty-one survey responders consented to record review. One thousand four hundred and twenty-seven (10%) received an OA (n = 616) or joint pain (n = 811) code with wide practice variation. Receiving an OA diagnosis was associated with age (75+ compared to 50-64 OR 3.25; 95% Credible intervals (CrI) 2.36, 4.53), obesity (1.72; 1.22, 2.33), and pain interference (1.45; 1.09, 1.92). Analgesia management was similar. Radiographic OA was common in both groups. A quarter of those with a joint pain record received an OA diagnosis in the following 6 years.

CONCLUSION

Recording OA diagnoses are less common than recording a joint pain symptom and associated with risk factors and severity. OA studies in primary care need to consider joint pain symptoms to understand the burden and quality of care across the spectrum of OA. Patients recorded with joint pain may represent early cases of OA with need for early intervention.

Appendicitis after right colectomy? How can this be possible?

This case report concerns a man with appendicitis following right colectomy.

Abstract P3-10-15: Quantitative Gene Expression by RT-PCR in Classic and Variant Forms of Lobular Carcinoma in Estrogen Receptor Positive Invasive Breast Cancer

Background: Classic lobular carcinoma is characterized by a distinctive morphology, loss of E-cadherin commonly due to mutation or deletion of CDH1 on chromosome 16q, and a variable clinical course (Pestalozzi J Clin Oncol. 2008 26:3006). Variants (pleomorphic, solid and alveolar) with distinct morphologies and potential differences in outcome have been described (Rosen 2009). Herein we explore the patterns of quantitative gene expression as measured by the 21 gene Oncotype DX® assay observed between ductal NOS (DC) and classic and variant lobular carcinomas. Material and Methods: All tumors analyzed in the Genomic Health laboratory from 6/1/04-3/31/10 were included. Central path used WHO criteria for classification of classic lobular (CL), solid & alveolar lobular (SAL), and pleomorphic lobular (PL) carcinomas. Quantitative expression of 16 cancer related genes was measured on a scale from 0 to 15 (relative to reference genes) where a 1 unit increment is associated with an ∼2-fold change in expression. Descriptive statistics for RS & individual genes [ER, PR, invasion gene group (IGG) & proliferation gene group (PGG)] among the different subtypes were obtained. Comparisons of means among the subtypes were adjusted to control the overall error rate under any complete or partial null hypothesis.

Results: DC accounted for 90.4% of 133,234 cases, CL 8.2%, SAL 0.7% and PL 0.8%. For all types a continuous range of RS was observed. DC had the greatest percentage of high risk RS followed by SAL, PL and CL. DC had the highest RS and CL had the lowest RS. SAL had the highest ER expression and CL had the lowest expression, but these results may refect a submission bias and are not population based. The proportion with the ER+/PR-phenotype was slightly different among the subtypes: SAL (24.2%) and PL (19.5%) had a higher incidence compared to DC (15%) and CL (15.6%). SAL had the highest PGG expression; CL had the lowest. DC had the highest IGG; CL had the lowest.

Discussion: Classic lobular carcinoma and the lobular carcinoma variants are characterized by differential patterns of gene expression. Outlier cases are not infrequent within each of the special subtypes in this large observational cohort. The variation in gene expression, noted by histologic subtype, will be presented in detail.

RS Distributions in Ductal NOS, Lobular and Lobular Variants

Arytenoid subluxation after a difficult intubation treated successfully with voice therapy

Arytenoid subluxation is a rare laryngeal injury that may follow instrumentation of the airway and present as hoarseness, vocal fatigue, stridor, dysphagia, odynophagia and sore throat. We report the case of an 88-year-old man with type 2 diabetes mellitus who developed this complication during a difficult intubation where a Macintosh laryngoscope and gum elastic bougie were used to facilitate intubation. Previously considered to play a minor role in treatment, voice therapy was used successfully in this patient to correct subluxation of the arytenoid, with prompt resolution of his symptoms.

Feasibility and Accuracy of Sentinel Lymph Node Biopsy in Clinically Node Negative Patients after Neoadjuvant Chemotherapy for Breast Cancer – A Systematic Review and Metaanalysis

BackgroundThe sentinel lymph node biopsy (SLNB) has become an accepted alternative to the axillary lymph node dissection (ALND) for pathologic evaluation of the axillary lymph node status in patients with early breast cancer and a clinically negative axilla. Patients with a negative sentinel lymph node are spared the ALND and its associated morbidities.Currently, there is insufficient evidence to recommend the use of SLNB in patients who have received neoadjuvant chemotherapy (NAC), and treatment of the axilla after neoadjuvant chemotherapy is an ALND.The use of neoadjuvant chemotherapy is increasing, and NAC has been shown to downstage both the primary tumour and axillary lymph nodes. Potentially, an additional proportion of patients who are node negative after NAC may be spared a full ALND and its attendant morbidities.AimsTo determine the feasibility and accuracy of SLNB in patients who have a clinically negative axilla after neoadjuvant chemotherapy for breast cancer.MethodsA systematic review of the English literature of SLNB in patients who have had neoadjuvant chemotherapy (NAC) was conducted and meta analyses performed. Studies selected had an identifiable group of patients with breast cancer who received neoadjuvant chemotherapy and were clinically node negative. These patients had a SLNB prior to the standard ALND regardless of outcome of the SLNB.ResultsTen studies that met the eligibility criteria were identified. A total of 449 patients were studied. Pooled analysis using the fixed effects model was used to calculate successful identification rate and accuracy parameters. The summary rate of identification of SLN was 94% [95% CI: 91.6% – 96.7%]. The pooled sensitivity of SLNB after NAC was 93% [95% CI: 88.5% – 96.8%] and the false negative rate 7.0% [95% CI: 3.2% – 11.5%].ConclusionSLNB in patients with a clinically node negative axilla after neoadjuvant chemotherapy is feasible and accurate.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1013.

The effect of rotational malalignment on X-rays of the wrist

This study evaluates the effect of rotational malposition of the wrist on measured radiographic parameters of the distal radius and carpus. Ten wrists from five healthy volunteers were imaged in varying degrees of rotation. The wrists were placed in a custom, calibrated jig and images were taken in 5 degrees increments to a maximum pronation and supination of 20 degrees . The results demonstrate the following: a steady decrease in the scapholunate and radioscaphoid angles with extremes of supination; an increase in palmar tilt with supination and a decrease in palmar tilt with pronation. The palmar tilt varied from -4 degrees to 15 degrees and the scapholunate angle ranged from 48 degrees to 29 degrees at the extremes of rotation. These results demonstrate how malrotation in X-ray positioning can have a significant effect on the apparent alignment of the distal radius and carpal bones. Measurements taken from poor X-rays typically fall outside the normal range and could adversely effect treatment decisions.

Pulmonary tuberculosis among patients visiting a voluntary confidential counseling and testing center, Cambodia

SETTING

Voluntary counseling and confidential testing center (VCCT), Battambang District, Cambodia.

OBJECTIVES

To determine newly diagnosed pulmonary tuberculosis (PTB) prevalence and predicting factors, and assess the utility of TB-related symptoms and yield of sputum microscopy and culture.

DESIGN

Cross-sectional survey using interview, sputum smears and cultures and human immunodeficiency virus (HIV) testing.

RESULTS

Of 496 participants, 29 (5.8%) had culture-confirmed PTB while 19 (65.5%) were acid-fast bacilli (AFB) smear-positive. PTB prevalence was higher (P < 0.001) in HIV-positives (20/124, 16.1%) than in HIV-negatives (9/372, 2.4%). On multivariable analysis, being HIV-positive, underweight (body mass index <18.5 kg/m(2)), rapid weight loss and age > or =35 years were predictors of PTB. Fever (93%) and hemoptysis (86%) had the highest sensitivity and specificity, respectively. The symptom complex of rapid weight loss, fever and hemoptysis detected all PTB cases (sensitivity 100%). Examination of three sputum smears with culture of the first sample detected 95% (19/20) of the HIV-associated PTB cases and 90% (26/29) overall.

CONCLUSIONS

TB is common in the VCCT setting, regardless of HIV status. The high prevalence of HIV and PTB among the participants warrants consideration of TB screening for all HIV suspects. Such screening through VCCT is feasible. Adding a single culture test to the evaluation of an initial sputum sample set will substantially increase case detection.

Prescribing pattern in Parkinson's disease: are cost and efficacy overriding factors?

Information on prescribing pattern of antiparkinsonian medications and factors influencing neurologists' choice of such drugs are important considerations in evaluating healthcare cost of Parkinson's disease (PD). We surveyed neurologists' perceived factors influencing their choice of drugs and actual prescribing pattern in PD. Three hundred and six patients at a tertiary hospital, diagnosed with idiopathic PD and who were dispensed antiparkinsonian drugs during a 6-month period were randomly selected. Patient demographics, type and dose of medications were analysed. A questionnaire survey evaluating the factors influencing choice of medications was administered to neurologists who practiced at the institution. The study population had a mean age of 64.4 years (SD +/- 9.9 years), and more than 80% were at Hoehn & Yahr stage 2-3. 92.3% of the study population were receiving levodopa and monotherapy, with levodopa being the most common treatment regimen. Patients who were prescribed levodopa were significantly older and at a later stage of disease compared to those without levodopa (p < 0.05). Only 26.8% of patients were prescribed dopamine agonists. In the survey, the neurologists cited severity of symptoms, and patients' intolerance of side effects, and efficacy as the most important factors influencing their choice of drugs. However, the actual prescribing pattern revealed a strong positive correlation of drug usage with cost subsidy by the institution. While factors affecting drug usage in PD are well recognised, cost and efficacy of a drug appear to be overriding practical factors in influencing usage pattern in clinical practice.

Independent contribution of elevated-rim acetabular liner and femoral head size to the stability of total hip implants

The use of an elevated-rim acetabular liner in total hip arthroplasty is widely accepted. We sought to determine quantitatively the amount of additional stability provided by the elevated-rim liner compared with the standard nonelevated liner. The stability of the hip with a 32-mm femoral head was compared with the standard 28-mm head. Our results show that a 15 degrees elevated-rim acetabular liner placed in the posterior quadrant increased hip stability by an additional 8.9 degrees of internal rotation. Similarly the 32-mm head provided 8.1 degrees of additional internal rotation. The increases were statistically significant (P<.0001). We did not encounter increased anterior dislocation intraoperatively. The findings of this study indicate that the 32-mm head may contribute to hip stability in primary total hip arthroplasty, and in instances in which a posterior approach is used, an elevated-rim liner placed in the posterior quadrant may contribute independently to hip stability.

In-line skating injuries

In-line skating has remained a popular recreational activity all over the world. The number of injuries seemingly reached a plateau in the late 1990s. However, there are still more injuries caused by in-line skating than from skateboarding, hockey or lacrosse and rugby. In 1997, the estimated annual cost of medical treatment for these injuries in the US was over $US4 billion. Adolescence still represents the largest group of skaters, both in participation and injury. Although 10- to 14-year-olds account for 60% of injuries, in 1996 the US Consumer Product Safety Commission reported nearly 1500 injuries in individuals 65 years and over. Risk factors for injury include inexperience, aggressive skating and amount of time spent skating. There are also more recent data to suggest that self-reported expert skaters are more likely to sustain an injury. Reluctance to use personal protective equipment (PPE) by in-line skaters remains high. The general consensus is that PPE is effective in reducing the incidence and severity of in-line skating injuries. Therefore, efforts should be made to increase awareness of risk factors for injury in all skaters; to increase use of safety equipment; to provide safe environments for skating; and to legislate skating laws that will protect skaters from injuries.

Contribution of acetabular labrum to articulating surface area and femoral head coverage in adult hip joints: an anatomic study in cadavera

The purpose of our study was to describe the gross anatomy of the adult acetabular labrum and to determine its contribution to the depth, surface area, and volume of the acetabulum. Fifty-five embalmed hips were studied. Each hip was disarticulated, and standardized measurements were taken. Calculations of the acetabular articulating surface area and volume, with and without the labrum, were performed based on these measurements. Average width of the acetabular labrum was 5.3 mm (SD, 2.6 mm). The labrum was wider anteriorly and superiorly than posteriorly. The surface area of the acetabulum without the labrum was 28.8 cm2; with the labrum, it was 36.8 cm2 (P < .0001). The volume of the acetabulum without the labrum was 31.5 cm3; with the labrum, it was 41.1 cm3 (P < .0001). There was no side-to-side difference in contribution of the labrum to either surface area or volume between right and left hips. Comparison of these indices for males and females showed statistically significant differences in absolute but not relative increases.

The effect of articular malposition after total shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement

The articular surface of the normal humeral head has a variable posterior and medial offset with respect to the central axis of the humeral shaft. Recreation of the normal humeral head shaft offset is postulated to be an important consideration during shoulder arthroplasty. However, the effect of humeral head malposition is unknown. The purpose of this study was to determine the effect of articular malposition after total shoulder arthroplasty on glenohumeral translation, range of motion, and subacromial impingement. Twenty-one human cadavers were dissected and tested with the use of an active or passive shoulder model. Range of motion and translation were recorded by means of an electromagnetic tracking device. The experiment was performed in 2 phases. For kinematics study, 11 cadaver shoulders were positioned both passively and actively from maximum internal rotation to maximum external rotation at 90 degrees of total elevation in the scapular plane. Three rotator cuff and 3 deltoid muscle lines of action were simulated for active joint positioning. Passive joint positioning was accomplished with the use of a torque wrench and a nominal centering force. The testing protocol was used for the natural joint as well as for 9 prosthetic head locations: centered and 2- and 4-mm offsets in the anterior, posterior, inferior, and superior directions. Repeated-measures analysis of variance was used to test for significant differences in the range of motion and translation between active and passive positioning of the natural joint as well as all prosthetic head positions. (2) For impingement study, 10 cadaver shoulders were used in a passive model, loading the tendons of the rotator cuff with a 30-N centering force. The humerus was passively rotated from maximum internal rotation (1500 Nmm) to maximum external rotation (1500 Nmm) by means of a continuous-recording digital torque wrench. Trials were performed with the use of centered, 4-, 6-, and 8-mm offset heads in the anterior, posterior, superior, and inferior positions before and after removal of the acromion and coracoacromial ligament. The relation between change in mean peak torque (with and without acromion), passive range of motion, and humeral head offset was analyzed by means of repeated-measures analysis of variance. In the kinematics study, total range of motion and all humeral translations were greater with passive joint positioning than with active positioning (P =.01) except for total superior-inferior translation and superior-inferior translation in external rotation. Anterior to posterior humeral head offset was associated with statistically significant changes in total range of motion (P =.02), range of internal rotation (P =.02), range of external rotation (P =.0001), and total anterior-posterior translation (P =.01). Superior to inferior humeral head offset resulted in statistically significant changes in total range of motion (P =.02), range of internal rotation (P =.0001), anterior-posterior translation during external rotation (P =.01), and total superior-inferior translation (P =.03). In the impingement study, there was a significant increase in torque from centered to 4-mm inferior offset (P =.006), 6-mm inferior offset (P <.001), and 8-mm inferior offset (P <.001). There was no significant increase in torque with superior, anterior, and posterior offsets. Glenohumeral motion significantly decreased from 129 degrees for centered head to 119 degrees for 8-mm superior (P =.002), 119 degrees for 8-mm anterior (P =.014), 118 degrees for 8-mm inferior (P <.001), and 114 degrees for 8-mm posterior (P =.001). Humeral articular malposition of 4 mm or less during prosthetic arthroplasty of the glenohumeral joint may lead to small alterations in humeral translations and range of motion. Inferior malposition of greater than 4 mm can lead to increased subacromial contact; offset of 8 mm in any direction results in significant decreases in passive range of motion. Therefore if subacromial contact is to be minimized and glenohumeral motion maximized after shoulder replacement, anatomic reconstruction of the humeral head-humeral shaft offset to within 4 mm is desirable.

Anatomy, histologic features, and vascularity of the adult acetabular labrum

Acetabular labrum tears have been implicated as a cause of hip pain in adult patients. Few studies describe the anatomy, histologic features, and microvasculature of the acetabular labrum and labral tears. Fifty-five embalmed and 12 fresh-frozen adult hips with a mean age of 78 years (range, 61-98 years) were studied. Of these, 96 % (53 of 55) of the hips had labral tears, with 74% of the tears located in the anterosuperior quadrant. Histologically, the fibrocartilaginous labrum was contiguous with the acetabular articular cartilage through a 1- to 2-mm zone of transition. A consistent projection of bone extends from the bony acetabulum into the substance of the labrum that is attached via a zone of calcified cartilage with a well-defined tidemark. Two distinct types of tears of the labrum were identified histologically. The first consisted of a detachment of the fibrocartilaginous labrum from the articular hyaline cartilage at the transition zone. The second consisted of one or more cleavage planes of variable depth within the substance of the labrum. Both types of labral tears were associated with increased microvessel formation seen within the tear. The acetabular labrum tear appears to be an acquired condition that is highly prevalent in aging adult hips. Labral tears occur early in the arthritic process of the hip and may be one of the causes of degenerative hip disease.

Ageing and fitness to work

Ageing workers can be found in almost all occupations. Assessment of fitness to work in these workers is important, as it aims to match their functional capacity (which is reduced compared to younger workers), to the demands of their work (which may remain the same as that for younger workers). This outcome of assessment is influenced by the interaction between functional capacity, state of health, the nature of work, and possibilities for work accommodation. The assessment of functional capacity should include physical, mental and social capacity, as well as assessment of any disability. In addition to clinical or laboratory measurements, several authors have suggested the use of a 'work ability index' for specific occupations as a practical means of selecting the appropriate worker for the job. This index can also be used for monitoring functional capacity. In addition, as for any fitness to work assessment, a good understanding of the nature of the work and the work environment is required, and possibilities for work accommodations considered. While changes in the work environment and working conditions can be made to suit the functional capacity of the ageing worker, the maintenance of functional capacity is another important issue. There is a place for a greater role for disease screening and health promotion for such workers.

Major pediatric hand trauma associated with fireworks

OBJECTIVES

To characterize the injury pattern and economic impact of major pediatric hand trauma secondary to fireworks.

DESIGN

Retrospective.

SETTING

Pediatric Level I trauma center.

INTERVENTION

N/A MAIN OUTCOME MEASUREMENTS: Fractures, amputations, soft tissue defects, length of hospitalization, number and type of procedures performed were obtained from charts, radiographs, and operative reports. Hospital charges were obtained from the billing office.

PATIENTS/PARTICIPANTS

Records of patients with a diagnosis of fireworks-related injuries admitted over a period of ten years were reviewed. Twenty-two patients were identified to have sustained twenty-two hand injuries. The group consisted of nineteen boys and three girls, with an average age of 9.3 years (range, 4 to 17 years).

RESULTS

There were thirty-one fractures, nineteen amputations, and one dislocation. The nineteen amputations occurred in nine hands. Local skin graft or flap coverage was required in six hands acutely, and delayed soft tissue procedures were performed on four hands. Four hands had digital neurovascular injuries; two required microsurgical repairs at the time of injury, and two were irreparable. Resource use included: average hospital stay of 4.3 days (range, 0 to 20), average number of trips to the operating room, 1.2 (range, 0 to 3), and average hospital charges of $11,582 (range, $1,035 to $39,489).

CONCLUSIONS

This study illustrates the severity of pediatric hand injuries associated with fireworks and the significant burden placed on medical resources in treating these injuries. Efforts toward public education and legislative reforms may help to prevent these unnecessary injuries.

Well-leg compartment pressures during hemilithotomy position for fracture fixation

OBJECTIVE

To evaluate the relationship between the well-leg compartment pressures and time during hemilithotomy position for fracture fixation.

DESIGN

Prospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ten patients who underwent intramedullary nailing of a fractured femur in the hemilithotomy position (with a well-leg holder).

INTERVENTION

Continuous pressure monitoring was achieved with in-dwelling slit catheters inserted into the calf compartments of the well leg. Baseline measurements were obtained in the supine position. After the leg was placed in the hemilithotomy position, compartment pressures were monitored throughout surgery.

MAIN OUTCOME MEASUREMENTS

Calf compartment pressures at baseline, during hemilithotomy position, and post-hemilithotomy were compared. The association between body mass index and compartment pressure was analyzed.

RESULTS

A consistent pattern was observed between compartment pressures and time. The curve was that of a step function in which the pressure increased as soon as the leg was placed in the well-leg holder and remained elevated until the leg was taken down. The pressure jumped from a baseline of 9.2 to 27.3 millimeters of mercury (mm Hg) (p<0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near-baseline level of 8.1 mm Hg (p<0.0001). A significant correlation was also found between the body mass index and leg pressure (R2 = 0.713; F = 0.002).

CONCLUSIONS

The use of the well-leg holder to maintain hemilithotomy position increases the calf compartment pressures dramatically and significantly. Therefore, we recommend avoiding this position for fracture fixation in at-risk patients.