A retrospective chart review of elderly patients who cannot weight bear following a hip injury but whose initial x rays are normal.

Falls causing hip injury are common among older people. In elderly patients who cannot weight bear following a hip injury but have normal initial x rays, management often involves admission to the clinical decision unit for analgesia, mobilisation and physiotherapy. A proportion of these patients require further investigation due to continuing pain or inability to weight bear. There is currently no agreed pathway for these patients, who often wait days for definitive diagnosis and management. Some centres suggest investigating such patients with magnetic resonance imaging at 24 h post-admission. This study aimed to define this patient group in terms of emergency management, number undergoing further investigation and outcome. A secondary aim was to produce a management pathway for these patients.

Association between aminolevulinate dehydrase genotypes and blood lead levels in children from a lead-contaminated area in Antofagasta, Chile.

Childhood environmental lead exposure in the city of Antofagasta, Chile, was generated by the accumulation of recently removed lead stores derived from mining activities for a long period of time. Susceptibility to harmful lead effects may be associated with polymorphisms of delta-aminolevulinic acid dehydratase (ALAD) because of the differential binding of lead to the codified proteins. We assessed the associations and possible interactions among the following variables: blood lead levels, ALAD genotypes, and distance to the source of lead contamination in Chilean children exposed to lead contamination in Antofagasta, Chile. Ninety-three children were recruited from schools located near a lead- contaminated area. Lead blood levels were measured by atomic absorption spectrophotometry. ALAD genotypes were determined by polymerase chain reaction and restriction fragment-length polymorphism analysis. The frequency of the ALAD-2 allele was estimated at 0.054. Children with the ALAD-2 genotype had higher blood lead levels than noncarriers (p = 0.06). As expected, blood lead levels were inversely correlated with the distance from lead stores. Interestingly, ALAD-2 carriers were more frequent within the area defined by a distance of 200 m from lead deposits (27%) than in areas >200 m (5%) away. Children living within a maximum distance of 200 m from the lead stores showed higher blood lead levels in ALAD-2 carriers (geometric mean = 16.4 microg/dl, range 6 to 27) than in noncarriers (geometric mean = 12.1 microg/dl, range 0 to 26) without achieving statistical significance (p = 0.13). A trend for higher blood lead levels in ALAD-2 carriers compared with ALAD-1 homozygous children has been observed. Because ALAD-2 frequency was higher in subjects living within 200 m from the lead deposits, we hypothesized that a long-term selective pressure against the presence of the ALAD-1 allele is the cause of the overrepresentation of the ALAD-2 allele in children living in proximity to the recently removed lead stores.

The use of a mobile lithotripter in the treatment of tennis elbow and plantar fasciitis.

OBJECTIVE: To evaluate the use of the mobile lithotripter in the treatment of tennis elbow and plantar fasciitis. METHOD: A prospective single blind randomised trial was performed on 24 patients with tennis elbow and 23 patients with plantar fasciitis, with a mean duration of symptoms of 11 months. All patients had failed one or more method of treatment--conservative, topical non-steriodal anti-inflammatory drugs (NSAID), steroid injection and/or surgery. The patients were divided into treatment and placebo groups. The placebo group received treatment with a clasp on the elbow/heel to stop penetration of shock waves. A baseline pain score was obtained using the Million Visual Analogue scale (0-10). The affected area was infiltrated with 3-5mls of 1% lignocaine. The treatment consisted of 2000 shock waves at 2.5 bars of air pressure with a frequency of 8-10Hz. A total of three treatments were given at an interval of two weeks, each lasting for three to four minutes. RESULTS: In the treatment groups, a final pain score at six months post treatment showed significant improvement (three or more points) in 78% of patients with tennis elbow and 93% of patients with plantar fasciitis. In the placebo groups, significant improvement was seen in one patient (9%) with tennis elbow. The other patients in the placebo groups did not show significant improvement. This was statistically significant (chi square test) for both conditions. CONCLUSION: The mobile lithotripter is an effective way of treating tennis elbow and plantar fasciitis but warrants further larger studies.

A case of primary amenorrhea, diabetes and anosmia.

This case details a patient with primary amenorrhea with an unusual cause. She presented at age 16 with short stature, minimal sexual development and no prior menses. Her history was significant for poorly controlled type 1 diabetes. She had been evaluated previously for growth hormone deficiency, and had received a short course of growth hormone therapy. Of greatest significance was the fact that she had also had a decreased sense of smell since her youth. Although a previous computerized tomography scan had been reported as normal, follow-up magnetic resonance imaging demonstrated the absence of olfactory bulbs. Smell testing confirmed the absence of smell and testing of gonadotropin releasing hormone demonstrated an inadequate response. All of these features suggested Kallmann syndrome. This syndrome commonly presents with delayed onset of puberty and decreased or absent sense of smell. There are also many associated features, and the disease is remarkable for its great genotypic and phenotypic variability. Current understanding of its pathogenesis, the commonly associated features of Kallmann syndrome and the impact of diabetes on growth and sexual development are reviewed.

The nasopharyngeal airway: a useful adjunct for the accident and emergency patient.

The use of an airway adjunct, usually an oropharyngeal airway, e.g. Guedel, is common in the Accident and Emergency department. In some patients, the oropharyngeal airway may be difficult to insert. This article considers the short term use of a nasopharyngeal airway.