Lateral ankle and hindfoot instability: a new clinical based classification.

Ankle sprains are one of the most common soft tissue injuries accounting for nearly 40% of sports injuries. There are large number of procedures for its treatment reported in the literature with largely good results. The ankle forms a functional unit with the subtalar joint. We present a new classification for peritalar lateral instability. There are two intents of this classification. Firstly, the classification demonstrates an assessment and treatment guideline for the many causes of peritalar lateral instability. The second use of the classification is for research purposes so that cohorts of patients can be accurately described and the efficacy of different operations in different groups can be properly assessed.

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: a prospective cohort validation study of a Welsh population.

OBJECTIVE: There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. METHOD: We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer-generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. RESULTS: A definitive diagnosis was established in 3457 patients. One hundred and eighty-six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72-81) was significantly higher than that of non-cancer patients (52, 95%CI 52-53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. CONCLUSION: The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.

Author Correction: Metagenomics of pigmented and cholesterol gallstones: the putative role of bacteria.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Conversion after laparoscopic cholecystectomy in England.

BACKGROUND: Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors. METHODS: Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year. RESULTS: The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001). CONCLUSIONS: Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Susceptibility of Candida albicans and Enterococcus faecalis to Chitosan, Chlorhexidine gluconate and their combination in vitro.

The aim of the present study was to analyse the sustain release of Chlorhexidine with Chitosan and to investigate the antimicrobial activity of 2% Chlorhexidine gel, 2% Chitosan gel and their combination against Candida albicans and Enterococcus faecalis. Sustain release of Chlorhexidine with Chitosan was determined using UV spectrophotometer. Then the inoculae of these organisms were used to make the lawn culture on sabouraud's dextrose agar and blood agar plates. Wells were prepared in these lawn cultures and filled with 2% Chlorhexidine gel, 2% Chitosan gel and their combination. The agar plates were incubated overnight at 37 degrees C and the zone of inhibition was examined after 48 h. Release of Chlorhexidine with Chitosan was better than plain Chlorhexidine release. Combination of Chlorhexidine and Chitosan showed maximum inhibitory zone for C. albicans (25.2 mm) and E. faecalis (26.0 mm). Plain Chlorhexidine gel showed intermediate inhibitory zone for C. albicans (20.6 mm) and E. faecalis (21.4 mm) and plain Chitosan gel showed minimum inhibitory zone for C. albicans (16.6 mm) and E. faecalis (11.0 mm). Carbopol which served as control did not have any antimicrobial effect. The present study suggests that 2% Chlorhexidine gel in combination with 2% Chitosan gel has the highest antimicrobial effect against C. albicans and E. faecalis compared with 2% Chlorhexidine gel or 2% Chitosan gel alone.

Assessment of a patient consultation questionnaire-based scoring system for stratification of outpatient risk of colorectal cancer.

BACKGROUND: The UK government's fast-track 2-week wait (2WW) rule and colorectal cancer guidelines aimed to detect patients at high risk of having colorectal cancer, but the yield has been poor. A patient consultation questionnaire (PCQ)-based scoring system may be an effective tool for prioritizing colorectal referrals. The aim of this study was to validate the system in a large and ethnically diverse population and to compare it with 2WW referrals. METHODS: Over a 1-year period, all colorectal referrals (2WW and traditional letters) at nine hospitals in Leicestershire were sent a PCQ to complete and return. A weighted numerical score (WNS), which reflects the patient's risk of having colorectal cancer, was calculated and compared with the hospital diagnosis. RESULTS: Of a total of 1422 PCQs returned, 83 patients were diagnosed with colorectal cancer. The 2WW referrals constituted 35.7 per cent of all referrals. The mean WNS of patients with colorectal cancer was significantly higher than that of the other patients (mean 76.3 versus 48.9 respectively; P < 0.001). For similar cancer detection rates (or sensitivity), the specificity of a WNS cut-off of 70 was significantly better than that of the 2WW system (82.7 versus 66.1 per cent; P < 0.001). CONCLUSION: The PCQ-based WNS system improves specificity for detecting colorectal cancer, particularly when the WNS exceeds 70.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in two children with cerebral palsy.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

Proximal femoral nail failures in extracapsular fractures of the hip.

PURPOSE: To review patients with proximal femoral nails (PFNs) in our hospital that developed complications and needed revision. METHODS: Between January 2000 and June 2006, records of 216 patients with PFN fixations for traumatic extracapsular trochanteric fractures (n=160), pathological fractures (n=23), and as a prophylactic measure for metastasis (n=33) were retrospectively reviewed. The injury mechanism, reduction technique and quality, and time to and cause of implant failure were recorded. RESULTS: 12 PFNs failed: 8 in the trauma group, 3 in the pathological group, and one in the prophylactic nailing group. Two PFNs broke at the proximal lag screw level at a later stage secondary to non-union of the pathological fractures. One broke at the level of the distal locking screw at an early stage, as the locking holes were too close to the fracture. CONCLUSION: Poorly reduced fractures tend to fail early, whereas late failures are due to non-union. Good reduction with minimal dissection, the use of appropriate nail length, and proper positioning of the nail and screws are necessary to avoid failure or revision.

Metagenomics of pigmented and cholesterol gallstones: the putative role of bacteria.

There is growing evidence for bacteria playing a role in the pathogenesis and formation of pigmented gallstones from humans. These studies mainly involved cultivation of gallstone-associated bacteria and 16S rRNA profiling, providing an indirect link between processes involved in gallstone formation by the bacteria in-situ. Here, we provide functional metagenomic evidence of a range of genes involved in bile stress response, biofilm formation, and anaerobic energy metabolism by Gram-negative Klebsiella in pigmented gallstones from a 76-year-old male patient. Klebsiella was also present in one cholesterol-type stone in a 30-year-old female patient who had additional cholesterol gallstones characterised by Gram-positive bacteria. Pigmented stones further revealed a predominance of genes involved in carbohydrate metabolism, whilst cholesterol stones indicated a profile dominanted by protein metabolism possibly reflecting known chemical differences between Gram-negative and Gram-positive biofilm matrices. Archaeal genes were not detected. Complementary carbon and hydrogen isotopic analyses of cholesterol within the patients' stones revealed homogeneity, suggesting a common diet or cholesterol biosynthesis pathway that has little influence on microbial composition. This pilot study provides a framework to study microbial processes that play a potential role in gallstone formation across markedly different types of stones and patient backgrounds.

Antimicrobial action of calcium hydroxide, chlorhexidine and their combination on endodontic pathogens.

BACKGROUND: The common recovery of Candida albicans and Enterococcus faecalis from failed root canals of teeth in which previous treatment has failed is notable. These organisms have been shown to be resistant to antimicrobial action of calcium hydroxide but are sensitive to chlorhexidine gluconate. The aim of the present in vitro study was to investigate the antimicrobial efficacy of calcium hydroxide paste, 2% chlorhexidine gel and their combination against Candida albicans and Enterococcus faecalis. METHODS: Inoculae of these organisms were used to make lawn cultures on Sabouraud's dextrose agar and blood agar plates. Wells were prepared with these lawn cultures and filled with calcium hydroxide paste, 2% chlorhexidine gel and their combination. The agar plates were kept overnight for incubation at 37 degrees C and the zone of inhibition was examined after 24 and 72 hours. RESULTS: The results suggest that 2% chlorhexidine gel alone is more effective at 72 hours than calcium hydroxide paste alone or in combination with 2% chlorhexidine gel against both the organisms, even though calcium hydroxide showed better antifungal efficacy against Candida albicans at 24 hours. CONCLUSION: In failed root canal treatments, 2% chlorhexidine gel may be a more effective intracanal medicament than calcium hydroxide paste or their combination against Candida albicans and Enterococcus faecalis.

Management of sports injuries of the foot and ankle: an update.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874-83.

Management of sports injuries of the foot and ankle: An update.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299-1311.

Mycotic keratitis: a study in coastal Karnataka.

Fungi were isolated from 67 cases out of the 295 cases of corneal ulcers investigated. Aspergillus species and species of Candida were the major fungal members isolated. Allescheria boydii was isolated from 3 cases, having no previous history of injury to the eye or infection with bacterial or viral agents. A boydii corneal infection is a rare occurrence. Higher incidence of mystic keratitis was seen among females than males. No relationship to seasonal changes could be established. Bacterial infection was associated in 46. 27% of the cases of mycotic keratitis and Staphylococcus was the predominant bacterial pathogen observed.

Cryptosporidium and isospora belli diarrhoea in immunocompromised hosts.

Cryptosporidium and isospora, two of the intestinal coccidian parasites known to be the causative agents of acute diarrhoea in animals, have now emerged as one of the main causes of prolonged life threatening diarrhoea in immunocompromised patients particularly so in patients with AIDS. Between June 1996 and December 1997, a total of 75 immunocompromised patients presenting with diarrhoea were investigated both for Cryptosporidium and Isospora. The study group consisted of cancer and AIDS patients with history of diarrhoea. Cryptosporidium oocysts were detected in 35 patients (46.7%). One of the faecal samples from an AIDS patient with diarrhoea showed the presence of both Cryptosporidium and Isospora oocysts. To the best of our knowledge, this is the second documented report of Isospora associated diarrhoea in an AIDS patient from India. The various techniques used for demonstration of these parasites were modified acid fast staining, Safranine Methylene-blue staining and direct immunofluorescence test.

Prevalence of rubella virus in suspected cases of congenital infections.

This study includes a total of 342 infants suspected of having congenital infections from January 1991-December 1993. Serum samples of these infants were tested for rubella specific IgM antibodies by mu ELISA. Of the total 342 infants, 52 (15.2%) were found to be positive for IgM antibodies to rubella virus. The commonest clinical presentation in infants with IgM antibodies to rubella virus was bilateral congenital cataract and hepatosplenomegaly.

Chromobacterium violaceum diarrhea.

This is the first case of Chromobacterium violaceum diarrhoea from coastal Karnataka reported in a 2 year 10 months old girl. Stool culture yielded Chromobacterium violaceum and was sensitive to ampicillin, gentamicin, chloramphenicol, erythromycin and septran. Patient completely recovered with ampicillin and gentamicin.

Rotavirus and bacterial enteropathogens causing acute diarrhea.

The etiology of rotavirus in acute diarrhoeal illness in children 0-5 years of age, admitted to the Pediatric wards of Kasturba Medical College Hospital, Manipal was studied, over a period of one year. Rotavirus in the faecal samples detected by the slide latex agglutination test accounted for 14.9% of the diarrheas with maximum incidence in the 7-12 months of age group (57.5%). Bacterial enteropathogens continued to play a significant role in diarrheal diseases. Salmonella enteritis was found more in the age group 0-6 months and shigellosis in 37-60 months. In a control study of 100 children who had no diarrhea, 2 were found positive for rotaviruses.

Activity of Ocimum sanctum (the traditional Indian medicinal plant) against the enteric pathogens.

Aqueous & alcoholic extracts of O. sanctum were prepared. Two concentrations of these extracts (30 mg & 60 mg) were tried against the enteric pathogens & candida albicans by Agar diffusion method. Wide zones of inhibition were observed at 60 mg concentration of extract. Aqeous extract showed wider zone of inhibition when compared to alcoholic extract. Aqueous extract showed wider zones of inhibition for Klebisella, E. Coil, Proteus & Staphylococcus aureus. Alcoholic extract showed wider zone for vibrio cholerae.

Correlation of the suicide phenomenon in Aeromonas species with virulence and enteropathogenicity.

Certain strains of mesophilic Aeromonads like A. hydrophila, A. veronii biotype sobria and A. caviae when grown in broth containing 0.5% glucose, undergo growth inhibition concomitant with acetate accumulation. As these strains become nonviable after 24 h, this phenomenon is termed suicide. We investigated suicidal strains of Aeromonas species as means of understanding animal virulence and enteropathogenicity. Non suicidal strains of A. Hydrophila showed and overall 88.8% lethality rate and non suicidal strains of A. veronii biotype sobria showed 83.3% lethality rate and was nil for its suicidal part. Of the two suicidal A. caviae strains tested, none were lethal. The present data suggest that the suicide phenomenon may explain strain specific [A. veronii biotype sobria, A. hydrophila] and species specific [A. caviae] virulence and enteropathogenicity.

Shigella and the fluorinated quinolones.

Between July 1996 to June 1997 a total of 531 Stool samples from cases of acute diarrhoea, dysentry, colitis admitted to Kasturba Medical College Hospital, Manipal were investigated. Shigella were isolated from 29 samples (5.46%). Out of them, Shigella flexneri were 16 (55.17%), Shigella boydii 8 (27.58%), Shigella dysentriae 3 (10.34%) and Shigella sonnei 2 (6.89%). Five strains of Shigella flexneri and one strain of Shigella dysentriae were found to show resistance to Nalidixic acid and the newer fluoroquinolones viz., Ciprofloxacin, Norfloxacin and Ofloxacin. The in vitro 'R' factor transfer study showed that the resistance was not transferable.