Union Rates of Talar Neck Fractures With Substantial Bone Defects Treated With Autograft.

BACKGROUND: This study evaluated the union rate of talar neck fractures with substantial bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis. METHODS: A case series at a level 1 trauma center was performed to identify consecutive patients who underwent operative fixation of talar neck fracture with autograft (Current Procedural Terminology codes 28445 and 20902) between 2015 and 2018. "Substantial bone defect" was defined as a gap greater than 5 mm in the sagittal plane and greater than one-third of width of the talar neck in the coronal plane. Postoperative foot computed tomographic (CT) scans were obtained for all patients. Primary outcome was union, and secondary outcomes were malunion, avascular necrosis (AVN), post-traumatic arthritis (PTA), and patient-reported outcomes (PROs). RESULTS: Twelve patients with 12 fractures were included in the series, with an average length of follow-up of 26 months (range: 7-55) The average age was 34 years (17-59), and the most common mechanism of injury was motor vehicle crash. The Hawkins classification of the fractures was 4 type II (2 type IIA and 2 type IIB) (33%) and 8 type III (67%). Four fractures (33%) were open fractures. Union was achieved in 11 patients (92%). There was 1 malunion (8%). AVN was identified on postoperative CT scans in 11 patients (92%). Three of these 11 eventually showed collapse. Ten patients (83%) had radiographic evidence of some degree of ankle PTA, and 12 patients (100%) had radiographic evidence of some degree of subtalar PTA. Average Patient-Reported Outcomes Measurement Information System-Short Form score was 37 (32-45) and average Foot and Ankle Ability Measure activities of daily living and sports subscale scores were, respectively, 61 (31-87) and 31 (0-71), respectively. Average visual analog scale score was 5 (0-10), and average Foot Function Index was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients. CONCLUSION: In this relatively small series, tibial autograft in primary osteosynthesis of comminuted talar neck fractures with substantial bone defects is associated with excellent union rates and low malunion rates. Despite high union rates, secondary outcomes of AVN with or without collapse, ankle and subtalar PTA, and relatively low PROs were common. LEVEL OF EVIDENCE: Level IV, case series.

An analysis of movement and discomfort of the female breast during exercise and the effects of breast support in three cases.

Breast pain is common during exercise, occurring in up to 56% of subjects in some surveys. This pain is mainly associated with the movement of breast tissue. In an attempt to analyse this movement and the resulting pain, the movement of the female breast tissue was quantified in four conditions of breast support ("sports bra", "fashion bra", "crop top" and bare breasted) during four different activities (running, jogging, aerobics march and walking). These activities represented general patterns of exercise for adult females in Australian society. All three subjects were healthy, active, young women of varying breast size (12B, 14B & 14C) that were typical of young women. Two of the subjects had noted breast pain whilst exercising. The results showed that wearing external support for the breast tissue reduced absolute vertical movement and maximum downward deceleration force on the breast. Support also reduced perceived pain. When compared to other forms of breast support a "sports bra" (brassiere designed for breast support whilst exercising) provided superior support for the breast in relation to the amplitude of movement, deceleration forces on the breast, and perceived pain. The data indicates that adult females should wear appropriate breast support to reduce perceived breast discomfort or pain. Of the three garments examined in this study, the fitted sports bra provided superior support and pain reduction.

Multicentre general practitioner assessment of 'Tenormin' and methyldopa.

A large scale study in general practice was set up to investigate the effects of transferring hypertensive patients from treatment with usually less than 1 g daily of methyldopa to atenolol ('Tenormin') 100 mg daily. The results demonstrate an improvement in blood pressure control with atenolol treatment and a reduction in the incidence of side-effects. The simple dosage regime, combined with proven effectiveness and a relative lack of side-effects makes atenolol a useful treatment for the hypertensive patient.

MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins?

Histopathological audit of positive circumferential resection margins (CRMs) can be used as a surrogate measure of the success of rectal cancer treatment. We audited CRM involvement in rectal cancer patients and the impact of the multidisciplinary team (MDT) on implementing a magnetic resonance imaging (MRI)-based preoperative treatment strategy. Data were collected on all newly diagnosed rectal cancer patients treated in our network between January 1999 and December 2002. Data were analysed for MRI prediction and histopathological assessment of CRM together with the MDT meeting treatment decisions. The CRM+ve rate of those discussed at MDT vs those not discussed were compared. We re-audited the CRM+ve rates 1 year after introducing a policy of mandatory preoperative MRI-based MDT discussion. Of the 298 patients diagnosed with rectal cancer, 39 (13%) were deemed palliative, 178 underwent surgery alone and 81 underwent neoadjuvant therapy. Of these, 62 out of 178 patients underwent surgery alone without MRI-based MDT discussion resulting in positive CRM in 16 cases (26%) as compared to 1 out of 116 (1%) in those patients with MDT discussion of MRI. Overall CRM+ve rate in all nonpalliative patients with or without MDT discussion was 12.5% (32 out of 256), significantly lower than the <20% rate (P<0.001) quoted in national guidelines. Re-audit in 98 consecutive patients following a change of policy produced a lower CRM+ve rate of 3% (1 out of 37) for all surgery alone patients and an overall CRM+ve rate of 7% (5 out of 70). In conclusion, MDT discussion of MRI and implementation of a preoperative treatment strategy results in significantly reduced positive CRM in rectal cancer patients.

Targeted mailing of information to improve uptake of measles, mumps, and rubella vaccine: a randomised controlled trial.

Uptake of the measles, mumps, and rubella vaccine in the United Kingdom has declined to levels that will allow outbreaks of these preventable diseases to occur. A leaflet sent with a personalized reminder did not increase vaccine uptake in children who had not been immunised at 21 months of age.

General professional training in public health medicine--the Leicestershire Senior House Officer scheme.

BACKGROUND: This study investigates the subsequent careers of the Senior House Officers (SHOs) who have passed through the Leicestershire SHO training scheme in public health medicine since its inception in 1981 and their views of the scheme. METHODS: Postal questionnaires were sent to past and current SHOs, using addresses compiled from personnel records, the Medical Directory and the General Medical Council Medical Register. One reminder letter was sent to non-responders. RESULTS: Of the 21 past SHOs, one is now a consultant and four are currently trainees in public health medicine. Other past SHOs have followed diverse careers but the largest group are now in general practice. The four past SHOs who are now trainees in public health gained no further clinical experience before obtaining registrar or lecturer posts. All past SHOs responded favourably when asked about the benefits of the scheme regardless of their subsequent career choice. CONCLUSION: The continuing need for high-calibre recruits to the specialty and the favourable response from past SHO trainees suggests that this scheme, and no doubt other similar schemes, should be making their benefits known to a wider audience.

Effective control of cisplatin-induced nausea using high-dose steroids and droperidol.

Seventy-three consecutive patients receiving cisplatin-containing chemotherapy regimens were treated with an initial dose of chlorpromazine (25 mg im), droperidol (1 mg iv, then 1 mg sc every 4 hours), and methylprednisolone (250 mg every 4 hours for four doses). Twenty patients received a combination chemotherapy protocol that included cisplatin at a dose of 40 mg/m2 iv (group 1) and 53 patients received a protocol that included cisplatin at a dose of 120 mg/m2 iv (group 2). The median age of all the patients was 58 years. Seventy-five percent of the patients in group 1 and 45% of those in group 2 had no vomiting at all; the remainder had limited and tolerable vomiting. These results in a group of elderly patients compare favorably with trials of other antiemetic programs.