'Ready-access' CT imaging for an orthopaedic trauma clinic.

'Ready-Access' to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result of the CT scan. It adds little time and cost to CT scanning lists.

Hypoxia-induced in vivo sickling of transgenic mouse red cells.

To develop an animal model for sickle cell anemia, we have created transgenic mice that express a severe naturally occurring human sickling hemoglobin, Hb S Antilles. Due to its low solubility and oxygen affinity, Hb S Antilles has a greater propensity to cause red cell sickling than Hb S. To make transgenic animals that express a high level of Hb S Antilles, the erythroid-specific DNAse I hypersensitive site II from the human beta-globin cluster was linked independently to the human alpha 2-globin gene and to the beta S Antilles gene. Embryos were injected with both constructs simultaneously and seven transgenic mice were obtained, three of which contained both the human alpha and the human beta S Antilles transgene. After crossing the human transgenes into the mouse beta-thalassemic background a transgenic mouse line was derived in which approximately half the beta-globin chains in the murine red cells were human beta S Antilles. Deoxygenation of the transgenic red cells in vitro resulted in extensive sickling. An increase of in vivo sickling was achieved by placing these transgenic mice in a low oxygen environment. This murine model for red cell sickling should help to advance our understanding of sickle cell disease and may provide a model to test therapeutic interventions.

A distant gene deletion affects beta-globin gene function in an atypical gamma delta beta-thalassemia.

We describe an English family with an atypical gamma delta beta-thalassemia syndrome. Heterozygosity results in a beta-thalassemia phenotype with normal hemoglobin A2. However, unlike previously described cases, no history of neonatal hemolytic anemia requiring blood transfusion was obtained. Gene mapping showed a deletion that extended from the third exon of the G gamma-globin gene upstream for approximately 100 kilobases (kb). The A gamma-globin, psi beta-, delta-, and beta-globin genes in cis remained intact. The malfunction of the beta-globin gene on a chromosome in which the deletion is located 25 kb away suggests that chromatin structure and conformation are important for globin gene expression.

Deep vein thrombosis in trauma: a prospective study of lower limb orthopedic trauma patients in Tianjin Hospital, China.

AIM: Pulmonary embolism is a third leading cause of death in trauma patients. The prevalence of deep vein thrombosis (DVT) in Asian countries is considered to be less than in Western countries. Our aim was to establish the rate of DVT in orthopedic trauma patients in Tianjin Hospital, to identify DVT risk factors and to support the use of prophylaxis. METHODS: Patients admitted between November 2003 and October 2004 with recent fracture had data collected prospectively to record type of fracture, mechanism of injury, history of DVT, blood transfusion requirements, operation details, extent of postoperative swelling, use of traction, immobilization, bandaging and patient positioning. Each patient had 3 duplex ultrasound examinations, the first within 24 h of admission. Patients requiring surgery had a second ultrasound within 2 days preoperatively, then 7 days postoperatively. Patients not requiring surgery had second and third ultrasound examinations 5 and 14 days after admission. RESULTS: There were 547 patients, median age 39.6 years (interquartile range: 28-50 years). DVT developed in 12.4% (95% confidence interval: 9.7-15.2%), most occurring with femoral shaft fractures (30.6%), 15.8% occurred with hip fractures, 14.5% with fractures around the knee and 10.8% with fractured tibia and fibula. Over half of DVTs (56.7%) developed within 3 days following injury. CONCLUSION: The incidence of DVT in Chinese orthopedic trauma patients approaches that in Western countries. Guidelines for DVT prophylaxis should be applied in China as in Western countries.

Simultaneous bilateral total hip arthroplasties in nonagenarians.

Total hip arthroplasty (THA) is an effective and durable treatment option for hip osteoarthritis (OA). As life expectancy continues to increase, so too will the demand for joint arthroplasty in the 10th decade of life, frequently in cases involving osteoarthritis of both hips. Simultaneous bilateral total hip arthroplasty (SBTHA) is a valuable therapeutic option in appropriately selected patients with bilateral degenerative hip disease, although its use in the very elderly is poorly reported on in the literature. A case of bilateral hip OA successfully treated with SBTHA in a nonagenarian is presented and the literature is reviewed.

Thrower's fracture of the humerus with radial nerve palsy: an unfamiliar softball injury.

A fracture of the normal humerus in a healthy young adult most commonly results from significant direct trauma. Throwing sports have become increasingly popular outside of North America and bring with them a novel injury mechanism for clinicians. A 21 year old woman sustained a "thrower's fracture" of the distal humerus and radial nerve palsy while throwing a softball. She was treated by internal fixation. Her fracture united, and radial nerve neurapraxia resolved after 8 weeks. Clinicians should be aware of this entity so that prodromal symptoms can be recognised early and thrower's fractures are not investigated unnecessarily.

Assessment of the "nearly normal" cervical spine radiograph: C2-C3 pseudosubluxation in an adult with whiplash injury.

C2-C3 pseudosubluxation is a well recognized normal anatomical variant in children and this physiological spondylolisthesis often makes the interpretation of paediatric cervical spine radiographs difficult. In direct contrast, this finding is rare in adults and has not been reported as a diagnostic difficulty following neck injury. We report a case of C2-C3 pseudosubluxation occurring in a 27 year old woman presenting with neck pain 1 week after a road traffic accident. Although there are effective radiological guidelines for cervical spine radiograph evaluation in children, there is no evidence that these can be applied to the adult cervical spine. Flexion and extension cervical spine views have limitations. In such cases, magnetic resonance imaging is required to definitively exclude pathological injury.

Primary total hip replacement--a survey of current practice and identifying changing trends.

Primary total hip replacement (THR) surgery is the most commonly performed and successful reconstructive procedure in orthopaedic surgery. We performed a survey of Irish Orthopaedic consultants to elucidate current practices of primary THR in elderly and young patients and identify changing trends. There was an 83% response rate. Most respondents use a cemented THR in elderly patients. 69% use a different THR in younger patients compared to older patients. 9% refer younger patients to hip replacement specialist consultant colleagues. 70% report changing to a new implant or new technique in younger patients and 45% use a hybrid THR, 15% an uncemented THR, 15% perform hip resurfacing and 47% use different bearing surfaces. Only 17% use the Charnley hip prosthesis in younger patients. Young and active patients will place high demands on a new THR and newer techniques, implants and bearing surfaces are being adopted in the hope of better outcomes.

Toxic megacolon: a life-threatening complication of high-dose therapy and autologous stem cell transplantation among patients with AL amyloidosis.

AL amyloidosis is a plasma cell disorder in which tissue deposition of immunoglobulin light chains leads to organ dysfunction. Recent reports of high-dose therapy with autologous stem cell transplantation for amyloidosis suggest higher response rates and extended survival compared to those seen with conventional chemotherapy. However, substantial treatment-related toxicity has been observed. This case series describes our institutional experience with autologous transplantation in four patients with amyloidosis with an emphasis on unique gastrointestinal toxicities, including toxic megacolon.

Malarial immunities in nineteenth-century west Africa and the Caribbean.

Military records make it possible to study the cause of death of British and French soldiers in West Africa and the Caribbean between about 1819 and 1914. These records are significant because they trace the quantitative pattern of immunity, or lack of it, among soldiers recruited in one region and serving in another. In the Caribbean, a childhood Caribbean disease environment produced no greater immunity to malaria than childhood in the British isles did. Childhood in West Africa, however, produced a degree of immunity to malaria is the Caribbean. For soldiers whose childhood disease environment was in Europe, increased deaths in the tropics were greater in West Africa than they were in the West Indies. The relative importance of malaria as a cause of death increased over this century, largely because death from other causes in the tropics declined faster than malaria deaths did. The greatest improvement in malaria death rates took place between the 1840s and 1870s as a result of empirical public health measures-not after the discovery of the mosquito vector at the end of the century.

The effects of the European Working Time Directive on surgical training: the basic surgical trainee's perspective.

BACKGROUND: On the 1 August 2009, the implementation of European Working Time Directive became European law and was implemented in Galway University Hospital (GUH). AIMS: The aim of the study is to ascertain the opinion of the 25 surgical SHOs in GUH on the effect of the implementation of an EWTD compliant roster had on the quality of their training. METHODS: A questionnaire was circulated to all 25 surgical SHOs. RESULTS: Twenty-two (88%) SHOs report a reduction in the quality of their training. 18 (72%) report a reduction in the development of their operative skills. The SHOs believed the EWTD Rotas would encourage Irish graduates to train abroad. CONCLUSIONS: Surgical training faces a challenge with the implementation of EWTD Rotas. Major changes need to be made to the surgical training structure to train surgeons to the highest standard and to retain Irish-trained surgeons in the Irish healthcare system.

Self-reported complication rates following primary total hip arthroplasty in Ireland: fact or fiction.

BACKGROUND: There are little data available on complication rates following primary total hip arthroplasty (THA) surgery in Ireland. AIMS: To determine self-reported complication rates and national data for primary THA. METHODS: A postal questionnaire surveyed Irish orthopaedic association consultant members. Additional data were obtained from the economic and social research institute (ESRI). RESULTS: We achieved an 83% response rate. 5,424 THAs were self-reported. Mean dislocation rates were 1%, but higher using a posterior surgical approach (p < 0.05). Mean deep infection rates were 0.4%. 29% were MRSA. No reduction was reported from additional barrier prophylaxes. Mean venous thrombo-embolism (VTE) rates were 3.5%. No reduction was reported from commencing prophylaxis preoperatively or extending treatment duration. National rates for dislocation, deep infection and VTE were 25.7, 0.87, and <0.1%, respectively. CONCLUSIONS: The creation of a National Hip Register is strongly recommended. A register would improve surgical practices and patient outcomes, and provide significant healthcare savings.

Disease exchange across the tropical Atlantic.

The fifteenth-century encounter between previously separate disease environments was not simply an encounter between Europe and the Americas. It was preceded by an encounter between Europe and tropical Africa and followed by a still-more-intense transmission of diseases across the tropical Atlantic, mainly from Africa to the Americas. This transmission principally involved smallpox, yaws, yellow fever, and falciparum malaria. Many other vector-borne diseases failed to make the transfer for lack of suitable vectors in the Americas. The African diseases contributed even more than those from Europe to the depopulation of the humid tropics in the Americas. They also set up conditions that made residence in the tropical Americas dangerous for newly arrived people from Europe.