The outcome following fixation of bicondylar tibial plateau fractures.

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of 75º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union. This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Right-sided congenital diaphragmatic hernia: A tertiary centre's experience over 25 years.

AIMS: To provide analysis on infants treated for right-sided congenital diaphragmatic hernia (RCDH) including mortality, neonatal morbidities, and associated congenital anomalies. METHODS: We reviewed records of infants admitted with RCDH from 1985 to 2010. RESULTS: A total of 160 infants with CDH were identified; of them 22 infants had RCDH, 14 (64%) were male and eight (36%) were female. Eleven of the 22 infants died (50%), of which seven (64%) were male, and four (36%) were female. Three infants (13.6%) were diagnosed prenatally, and 19 (86.4%) were diagnosed postnatally. A statistically significant association with mortality was observed for low five minute Apgar score (OR = 8; 95% CI: 1.24-51.5), and high alveolar-arterial gradient >400 (OR = 25.7; 95% CI: 2.2-298.5). Fourteen infants (64%) underwent surgical correction, three (21.4%) infants who underwent surgery died. Three infants were discharged with oxygen supplementation and tube feeding at home, and one on sildenafil. No statistical significance was observed between other variables and mortality/morbidity. We observed a change in practice in relation to timing of surgery allowing stabilisation of patient prior to surgery. Average in-patient stay for RCDH infants was 23.5 days (range: 0-112), compared with the total in-patient mean stay of 10.5 days. CONCLUSIONS: Low five minute Apgar score, and high alveolar-arterial gradient were significant predictors of mortality. RCDH is associated with high mortality (50%), prolonged length of stay and other anomalies. In recent years, we observed an improving trend for survival.

The value of a CT-guided fine needle aspirate in infants with lung abscess.

OBJECTIVE: To describe the range of pathogens isolated from a lung abscess in infants less than one year of age. To assess the role of direct culture from the abscess. METHODS: The two index cases were managed in 2002. An institution-based review was conducted of all infants up to one year of age diagnosed with a lung abscess between 1989 and 2002. Data sources were hospital's disease index and Neonatal Intensive Care Unit Audit database using ICD9 and ICD10 diagnostic codes for 'lung abscess'. RESULTS: Five infants, under the age of one year, were treated for a lung abscess. In the one case where the abscess was left-sided it was associated with a congenital cystic adenomatoid malformation of the lung. Pathogens were isolated following direct culture of the abscess in four cases. In three cases a single pathogen was isolated: pseudomonas aeruginosa, staphylococcus aureus and haemophilus influenzae. In one case a mixture of escherichia coli, streptococcus milleri and an anaerobe, propionibacteria, were cultured. Antibiotic therapy was directed at the identified pathogen(s) in all four cases. There was no mortality or recurrence. CONCLUSION: Predisposing factors for a lung abscess in infancy include prematurity, assisted ventilation, congenital lung anomaly and aspiration. Given the range of potential pathogens, direct culture by CT-guided fine needle aspiration is recommended to direct appropriate intravenous medical therapy provided the abscess is located peripherally.

Gastroschisis: determinants of neonatal outcome.

This retrospective study elicits information regarding the dependence of neonatal outcome in gastroschisis upon: (1) the mode of delivery, (2) place of birth, (3) time for birth to surgery, (4) method of closure, (5) time from operation to commencement of first enteral feeds. The neonatal intensive care database from five major tertiary centres was used to identify 181 neonates with gastroschisis from 1990 to 2000. There were 8 deaths. There were no significant differences in outcome for infants delivered vaginally (102) versus Caesarean section (79), those born near the tertiary centre (133) as compared to infants born away (48), ones operated within 7 hours (125) compared with those operated after 7 hours (56), with delayed closure (30) versus primary closure (151). Neonates fed within 10 days of operation (85) had significantly lower incidence of sepsis, duration of TPN and hospital stay when compared to those fed after 10 days (96). Early commencement of feeds decreases the incidence of sepsis, duration of total parenteral nutrition (TPN) and hospital stay. Place of delivery, mode of delivery, time to surgery and type of closure do not influence neonatal outcome.

Congenital lobar emphysema: Like father, like son.

Congenital lobar emphysema (CLE) is an uncommon cause of progressive respiratory distress that typically presents in the first few days of life. There has been a previous report of CLE in a mother and daughter. The authors describe 2 cases involving the right upper and middle lobes in a father and son secondary to relative deficiency of the bronchial cartilage. This provides additional evidence for inherited factors in the etiology of CLE.

Effects of cotinine on information processing in nonsmokers.

Cotinine, the major proximate metabolite of nicotine, is present in smokers in higher concentrations and for a longer time than nicotine, yet its effects on information processing have not previously been reported. We studied the cognitive effects of cotinine in non-smokers. Sixteen subjects were tested on three doses of cotinine (0.5, 1.0, and 1.5 mg cotinine base/kg), and placebo, on a choice reaction time (RT) task and on a verbal recall task with short and long lists. Cotinine significantly impaired recall on the long list and displayed non-significant but generally consistent dose-related slowing of RT and N100 latency. The acute effects of cotinine were small, and probably do not account for the cognitive deficits observed in tobacco withdrawal, although the cognitive effects of chronic cotinine administration need to be investigated.

A low dose of subcutaneous nicotine improves information processing in non-smokers.

Many studies have found that cigarette smoking or nicotine improves mental functioning in abstinent smokers. An unresolved issue is whether this improvement is due primarily to a direct facilitation of performance or to relief of the impairment caused by nicotine withdrawal. We evaluated the performance of 12 non-smokers before and twice (15 and 45 min) after a subcutaneous injection of 0.8 mg nicotine, 0.8 ml saline, and a control no treatment, on a choice reaction time (RT) task. Each treatment was given on a separate day; the control day was given on the first session. The order of nicotine and saline was balanced between subjects, and injections were given double-blind. The RT task manipulated stimulus and response processing. These manipulations consisted of two levels of stimulus complexity and two levels of response complexity, resulting in four task conditions. These manipulations along with latency measures of the event-related potential were used to identify the components of processing that mediated nicotine's effects on performance. During each active drug session blood nicotine levels, cardiovascular, and subjective responses were measured before and after each of the three tests (pre-drug, 15 min and 45 min post-drug). For the information processing measures only the comparisons of the pre- and 15-min post-test showed significant drug effects. Nicotine compared to saline significantly increased the number of responses at the fast end of the RT distribution. However, there were no changes in accuracy. Nicotine also speeded mean RT compared with saline or the control day, but the effects were only significant for the control-nicotine comparison.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of the analgesic efficacy and cost-effective use of long-acting local anesthetics in outpatient third molar surgery.

Bupivacaine hydrochloride, an amide-type of long-acting local anesthetic was compared with lidocaine hydrochloride to determine its analgesic efficacy and its cost-effective use in an oral and maxillofacial surgery private practice. The results show that 0.5% bupivacaine hydrochloride provides greater analgesia than 2% lidocaine, with an insignificant cost increase to the operating surgeon.

Faecal chymotrypsin concentrations in neonates with cystic fibrosis and healthy controls.

Specimens of meconium and random stools were collected sequentially from 25 healthy newborn babies over the first 8-14 days of life. The stool chymotrypsin concentrations increased from birth to a maximum at 4 days of age and then fell again over the next four days. The lowest individual stool concentrations either side of the four day peak were both, coincidentally, 120 micrograms/g stool. In a second group of 22 newborn babies suspected of meconium ileus and later confirmed to have cystic fibrosis, faecal chymotrypsin concentrations were all appreciably reduced. In eight babies, also with suspected meconium ileus but with negative sweat tests, chymotrypsin concentrations were within the healthy newborn range. Measuring faecal chymotrypsin concentrations is a reliable procedure for identifying pancreatic exocrine insufficiency in the newborn.

A screening method for measuring somatomedin B protein binding in serum from children with growth retardation.

A simple method which uses 100 microliter serum has been developed to measure the binding of somatomedin B (SMB) to protein in serum from normal children, adults, and patients with growth hormone deficiency. 125I-labelled SMB was used as binding ligand. The correlation between the binding of label by the proposed procedure and by an immunoelectrophoretic technique was acceptable (r = 0.73; P less than 0.02). The mean percentage of label bound to protein in serum from patients with deficiencies of growth hormone or other trophic hormones was significantly (P less than 0.001) lower than that for controls. The physicochemical characteristics of a specific binding-protein suggested that a protein with low capacity (160 pmol/l) and low Ka (4.37 X 10(6) l/mol was present in serum, in addition to a high concentration of alpha globulin(s) which also bound 125I SMB.