Osteochondral fractures of the knee in skeletally immature patients: short term results of operative fixation using Omnitech screws.

PURPOSE: Osteochondral fractures in skeletally immature patients are rare. A retrospective case series is reported looking at the use of Omnitech compression screws for these injuries. METHOD: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Eastbourne Miami-J Protocol: a Pilot Study for the Care of Cervical Injuries in the Community.

UNLABELLED: PURPOSE OF THE STUDY The aim of this pilot study was to develop The Eastbourne Miami-J Protocol for care of cervical injuries within the community. Led by orthopaedic senior practitioners, a multidisciplinary approach was developed to provide education and collar care for patients on a weekly basis. MATERIALS AND METHODS A total of 51 patients (17 male and 33 female), mean age 74 years (21 to 95) with CT confirmed cervical injuries during November 2010 and May 2014 followed the Eastbourne Miami-J Protocol. RESULTS Patients required collar care on average for 7.25 weeks. Thirty-two patients had single level cervical injuries with C2 the commonest. Complications included: 6 patients with psychosocial issues; 10 patients with skin erythema due to ill-fitting collars and 2 patients with skin breakdown requiring dressings. CONCLUSION The Eastbourne Miami-J protocol demonstrates that a multidisciplinary approach, championed by the casting department, can provide care for patients with cervical injuries within the community. KEY WORDS: cervical spine, C-spine, cervical collar, community, rehabilitation.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws.

PURPOSE OF THE STUDY: Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients. MATERIAL AND METHODS: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

The Eastbourne Trauma Assisted Discharge Scheme (TADS) Reduces Length of Stay in Hip Fracture Patients.

UNLABELLED: PURPOSE OF THE STUDY The aim of this prospective study; The Trauma Assisted Discharge Scheme (TADS), was to set up a new model of postoperative care for patients following a fractured hip, addressing the need for efficiency, cost effectiveness and meeting local demand. MATERIAL AND METHODS All patients with hip fractures between December 2010 and December 2011, meeting the TADS inclusion criteria were enrolled in the study. Innovative use of staff within existing budgets helped create a TAD team who with the use of defined patient goals and a link nurse provided a seamless transition from acute to community services. RESULTS One hundred and sixteen patients followed the TADS pathway; the majority aged 80-89 years and independent prior to falling. A total of 35 patients underwent dynamic hip screw fixation; 55 hemiarthroplasty, 11 total hip replacement and 11 cannulated screw fixation. The average length of in-hospital stay was 8.6 nights. The TADS reduced the average length of stay by 4.78 days. CONCLUSION TADS has the potential to be used as a model of care in other specialities and is easily transferable to the wider NHS. KEY WORDS: continuous quality improvement, quality improvement, surgery, cost-effectiveness, ambulatory care.

Supportive care of neurodegenerative patients.

Neurodegenerative illnesses are notorious for paucity of treatments and relentless clinical progression. Illness may follow a relatively acute presentation, as is seen with primary brain tumors such as glioblastoma or have a more insidious onset with a slower yet unyielding course, such as that seen in Parkinson's disease. Though disparate in presentation, these neurodegenerative illnesses are universally terminal, and both the patients and their families benefit from the intervention of supportive care in conjunction with primary disease management. Supportive palliative care has been shown to improve quality of life, enhance patient outcomes, and often extend patient life-but such care needs to be tailored. This clinical commentary examines the role of supportive palliative care in the management of neurologic patients, comparing and contrasting glioblastoma patients with idiopathic Parkinson's disease patients. Both patient populations are high utilizers of healthcare resources, require active management of multiple symptoms, and have high caregiver burden which underscores the need for supportive services in conjunction with disease management provided by the primary care team. Review of prognostication, patient and family communication, trust and relationship building, and complementary medicinal approaches are explored for these two diseases which broadly represent two differing poles of incurable neurological illness.

Case series of 17 modified Weil's osteotomies for Freiberg's and Köhler's II AVN, with AOFAS scoring pre- and post-operatively.

BACKGROUND: Treatment for metatarsal head avascular necrosis is largely conservative. For severe or refractory cases there are various surgical options. METHODS: We have performed a 'modified Weil's osteotomy' of the distal metatarsal in order to manage this problem. We present the largest case series, to our knowledge, with 17 such cases. The patients were scored pre- and post-operatively using the AOFAS Forefoot scoring system. RESULTS: We found that this procedure provided a mean score improvement of 36 points, with a complication rate of 5.9%. CONCLUSION: We would advocate this modified osteotomy as an effective, reliable and safe treatment option.

Infection in knee replacements after previous injection of intra-articular steroid.

We reviewed 231 patients who had undergone total knee replacement with an AGC (Biomet) implant over a period of 2.5 years. After applying exclusion criteria and with some loss to follow-up, there were 144 patients available for study. These were divided into two groups; those who had received intra-articular steroid in the 11 months before surgery and those who had not. There were three deep infections, all of which occurred in patients who had received a steroid injection. The incidence of superficial infection was not significantly different in the two groups. Five patients had undergone investigation for suspected deep infection because of persistent swelling or pain and all of these had received an intra-articular injection pre-operatively. We conclude that the decision to administer intra-articular steroids to a patient who may be a candidate for total knee replacement should not be taken lightly because of a risk of post-operative deep infection.

Use of palliative end points to evaluate the effects of mitoxantrone and low-dose prednisone in patients with hormonally resistant prostate cancer.

PURPOSE: This phase II study was designed to assess the effects of mitoxantrone with prednisone in patients with metastatic prostate cancer who had progressed on hormonal therapy. The methods of assessment included quality-of-life analyses, pain indices, analgesic scores, and the National Prostatic Cancer Project (NPCP) criteria. PATIENTS AND METHODS: Patients received mitoxantrone 12 mg/m2 intravenously every 3 weeks plus prednisone 10 mg orally daily. All had a castrate serum testosterone and Eastern Cooperation Oncology Group (ECOG) performance status < or = 3, and had not received prior chemotherapy. Every 3 weeks, analgesic intake was scored, and a present pain intensity (PPI) record and visual analog scale (VAS) describing pain were collected. Every 6 weeks, the European Organization for Research and Treatment of Cancer (EORTC) core quality-of-life questionnaire plus a prostate-specific module were completed. A palliative response was defined as a decrease in analgesic score by > or = 50% or a decrease in PPI by > or = two integers without any increase in the other. RESULTS: Twenty-seven patients were entered onto the study. Nine of 25 (36%) assessable patients achieved a palliative response maintained for > or = two cycles (range, two to eight or more). Improvements in mean PPI and VAS pain scores after each cycle of therapy (P < .05) were seen. Quality-of-life analysis showed improvements in social and emotional functioning, and in pain and anorexia. Using NPCP criteria, one patient achieved a partial response (PR) and 12 had stable disease; one of seven patients with measurable disease had a PR. No serious nonhematologic toxicity was experienced, and there were no episodes of febrile neutropenia. CONCLUSION: Mitoxantrone with low-dose prednisone is a well-tolerated treatment regimen that has some beneficial effects on disease-related symptoms and quality of life for patients with advanced prostate cancer.

An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales.

OBJECTIVES: To survey of the structure, processes and organisation of renal satellite units (RSUs) in England and Wales (Phase 1), and to compare the effectiveness, acceptability, accessibility and economic impact of chronic haemodialysis performed in RSUs compared to main renal units (MRUs) (Phase 2). DATA SOURCES: Phase 1: all renal satellite units in England and Wales. Phase 2: haemodialysis patients in a representative sample (based on geography, site, private--public ownership, medical input) of 12 RSUs and their MRUs. REVIEW METHODS: Phase 1 consisted of a questionnaire survey. Semi-structured interviews were held in a representative sample of 24 RSUs with the senior clinician, senior nurse and manager. Phase 2 consisted of a cross-sectional comparison of patients in these RSUs and patients in the parent MRUs deemed suitable for satellite care by senior staff. Clinical information was obtained from medical notes and unit computer systems. Generic and disease specific health-related quality of life (HRQoL) measures were used. Co-morbidity was assessed by the Wright/Khan Index, the Lister/Chandna score, the Modified Charlson Index, and the Karnofsky Performance Score. Statistical analyses compared RSU versus MRU patients and took account of the paired and clustered nature of the data. RESULTS: In Phase 1, responses were received from 74/80 (93%) of RSUs; 2600 patients were being treated in these RSUs. The interviews were generally positive about the impact of RSUs in terms of improved accessibility and a better environment for chronic haemodialysis (HD) patients, and in expanding renal replacement therapy patients (RRT) capacity. In Phase 2, some 82% of eligible patients took part, 394 patients in the 12 RSUs and 342 in the parent MRUs. The response rate was similar in both groups. There were no significant differences in clinical processes of care. Most clinical outcomes were similar, especially after pooled analysis, although a few parameters were statistically significantly different -- notably the proportion achieving Renal Association Standards for adequacy of dialysis as measured by the urea reduction ratio (URR) was higher in the RSU patients. Patient-specific quality of life did not differ except on the patient satisfaction questions from the KDQOL, which were scored higher by the RSU sample. Strength of preference for health status on and off dialysis was very similar between the groups, as were EQ-5D utilities. Major adverse events were not common in the RSU patients, although there were many hypotensive episodes on HD, a proportion of which affected the duration of the HD session. Of the costs measured, the only difference that was statistically significant was for District Nurse visits. Of particular note was that despite the MRU group having a higher proportion of patients hospitalised, this did not translate into a statistically significant budgetary impact in terms of the total cost per patient of hospitalisations or mean cost per patient per hospitalisation. CONCLUSIONS: This study has shown that RSUs are an effective alternative to MRU HD for a wide spectrum of patients. They improve geographic access for more dispersed areas and reduce patients' travel time, and are generally more acceptable to patients on several criteria. There does not seem to be an adverse impact of care in the RSUs although comparative long-term prospective data are lacking. The evidence suggests that satellite development could be successfully expanded; not all MRUs have any satellites and many have only a few. No single RSU model can be recommended but key factors would include local geography, the likely catchment population and the type of patients to be treated. There is a need for more basic budgetary information linking activity and expenditure to be available and more transparent, to perform at least an insightful top-down costing of the two care settings. Other areas suggested for further research include: a comparison of adverse events occurring in MRUs and RSUs with longer duration and larger numbers to identify more severe events, along with the more research into the scope for preventing such events, and a study into the patients deemed ineligible for satellite care. International comparisons of satellite care would also be useful.

Absorption of nicotine from small cigars.

The absorption of nicotine from cigars was measured in 7 male subjects who each smoked a single small cigar containing 14C-nicotine. The proportion of nicotine in the mainstream smoke delivered to the smoker's mouth was greater than that observed for cigarettes, but the proportion of nicotine in the cigar smoke which was retained by the smoker was about the same. The total dose of nicotine retained varied between 1 and 4.5 mg. Arterial plasma concentrations of nicotine were as high as those achieved by cigarette smoking but rose more slowly. Some nicotine from small cigars is absorbed by inhalation of the smoke into the lungs and some by buccal absorption.

Effects of nicotine on electrocortical activity and acetylcholine release from the cat cerebral cortex.

1. The effects of small amounts of nicotine on electrocortical activity and central acetylcholine (ACh) release have been studied on anaesthetized cats.2. The most common effect of nicotine given intravenously in a dose of 2 mug/kg every 30 sec for 20 min was to cause desynchronization of the electrocorticogram, indicating cortical activation, and an increase in the release of cortical ACh.3. A larger dose given less frequently (4 mug/kg every min for 20 min) caused, in some experiments, an increase and in others a decrease in cortical activity. Such changes were accompanied respectively by an increase or decrease in cortical ACh output.4. The amounts of nicotine that affected the electrocorticogram and ACh release are probably similar to those absorbed by the cigarette smoker who inhales.5. The effects of nicotine on the electrocorticogram were transient, but the effects on ACh were prolonged. This suggests that at least two pathways are involved in the nicotine response.

Evaluation of a low to middle tar/medium nicotine cigarette designed to maintain nicotine delivery to the smoker.

A specific objective of this 6-week crossover study was to determine how 21 regular smokers of middle tar cigarettes changed their smoking behaviour and uptake of smoke constituents, when switching to either lower tar cigarettes capable of delivering amounts of nicotine similar to a conventional middle tar cigarette (maintained nicotine product), or to conventional low tar/low nicotine cigarettes. Subjects visited the laboratory every 2 weeks for detailed assessment of their smoking behaviour. Weekly per capita consumption was similar for all three cigarettes. They were smoked with variable intensities (low tar greater than maintained nicotine greater than middle tar), the tendency being for larger puff volumes, faster puffing and increased puff duration with the low tar cigarettes. The maintained nicotine cigarette was preferred to the middle tar cigarette, although acceptability ratings of the three cigarettes only differed marginally. The nicotine absorbed from the maintained nicotine and middle tar cigarettes was similar and significantly greater than the levels achieved from the low tar cigarettes. Intake of carbon monoxide into the mouth and absorption into the blood stream was lower for the maintained nicotine cigarette than for the middle tar cigarette, with the low tar cigarette occupying an intermediate position. Derived estimates of tar intake suggested reduced intake of tar into the respiratory tract (around 25%) from the maintained nicotine product relative to the middle tar product. The possible advantages of switching to maintained nicotine cigarettes is discussed.

Optimization of photoconducting receivers for THz spectroscopy.

We have studied the sensitivity and noise of optically gated dipole receivers made from ion implanted Si and GaAs in an optimized time domain THz spectrometer. The spectrometer uses a room temperature, dc biased, semi-insulating GaAs stripline source capable of generating up to 30 microW average power. The 10% amplitude system bandwidth for 10 microm (50 microm) dipole receivers is 3 THz (1.5 THz). A dynamic range of 4 x 10(5) Hz(-1/2) is achieved using a 10 microm dipole GaAs receiver and 2 x 10(6) Hz(-1/2) using a 50 microm dipole for a total laser power of 110 mW and THz beam power of 20 microW. The dynamic range achieved with comparable silicon receivers is a factor of 2 smaller.

Elevated hepcidin at HIV diagnosis is associated with incident tuberculosis in a retrospective cohort study.

Hepcidin inhibits ferroportin-mediated iron efflux, leading to intracellular macrophage iron retention, possibly favoring Mycobacterium tuberculosis iron acquisition and tuberculosis (TB) pathogenesis. Plasma hepcidin was measured at human immunodeficiency virus (HIV) diagnosis in a retrospective HIV-prevalent, antiretroviral-naïve African cohort to investigate the association with incident pulmonary and/or extra-pulmonary TB. One hundred ninety-six participants were followed between 5 August 1992 and 1 June 2002, with 32 incident TB cases identified. Greater hepcidin was associated with significantly increased likelihood of TB after a median time to TB of 6 months. Elucidation of iron-related causal mechanisms and time-sensitive biomarkers that identify individual changes in TB risk are needed.