Proximal femoral resection without post-operative traction for the painful dislocated hip in young patients with cerebral palsy: a review of 79 cases.

Proximal femoral resection (PFR) is a proven pain-relieving procedure for the management of patients with severe cerebral palsy and a painful displaced hip. Previous authors have recommended post-operative traction or immobilisation to prevent a recurrence of pain due to proximal migration of the femoral stump. We present a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35 male, 28 female), none of whom had post-operative traction or immobilisation. A total of 71 hips (89.6%) were reported to be pain free or to have mild pain following surgery. Four children underwent further resection for persistent pain; of these, three had successful resolution of pain and one had no benefit. A total of 16 hips (20.2%) showed radiographic evidence of heterotopic ossification, all of which had formed within one year of surgery. Four patients had a wound infection, one of which needed debridement; all recovered fully. A total of 59 patients (94%) reported improvements in seating and hygiene. The results are as good as or better than the historical results of using traction or immobilisation. We recommend that following PFR, children can be managed without traction or immobilisation, and can be discharged earlier and with fewer complications. However, care should be taken with severely dystonic patients, in whom more extensive femoral resection should be considered in combination with management of the increased tone.

Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature.

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.

Integrated positron emission tomography-computed tomography does not accurately stage intrathoracic disease of patients undergoing trimodality therapy for malignant pleural mesothelioma.

INTRODUCTION: The results of trimodality therapy for malignant pleural mesothelioma (MPM) are related to stage. Staging can be carried out by computed tomography (CT), magnetic resonance imaging and fluorodeoxyglucose positron emission tomography (FDG-PET), but all modalities suffer from limitations. We investigated whether integrated PET-CT improved the intrathoracic staging of patients undergoing trimodality therapy for MPM. METHODS: Twenty consecutive patients [18 male, median age 62 years (range 52-68)] who underwent 24 PET-CT scans prior to extrapleural pneumonectomy (EPP) as part of trimodality therapy for MPM were reviewed. The intrathoracic stage of MPM on PET-CT was compared with the pathological stage following examination of the resected specimen. Patients excluded from radical surgery due to metastatic disease were not studied here. RESULTS: PET-CT was performed a median of 119 days (range 2-229) prior to EPP. 16 scans were performed after talc pleurodesis. Nine scans were performed following chemotherapy. PET-CT correctly identified the T stage in 3 patients, overstaged 4 and understaged 17. Six scans failed to identify disease that later proved to be pT4. Nine patients were found to have pN2 disease; PET-CT identified N2 disease with a sensitivity of 11.1 %, specificity of 93 % and accuracy of 66 %. Previous talc pleurodesis did not alter the accuracy of PET-CT staging. CONCLUSIONS: In one of the few studies of integrated PET-CT in MPM that has complete pathological correlation we have shown that PET-CT does not accurately identify advanced tumor stage (T4) or mediastinal nodal disease (N2). The role of PET-CT staging prior to EPP lies outside the affected hemithorax.

The superficial ulnar artery: incidence and calibre in 95 cadaveric specimens.

The superficial ulnar artery (SUA) is an anatomical variation of the upper limb vasculature with a prevalence of 0.7-9.4% in the population. The importance of this variant is that it may be cannulated inadvertently by an unsuspecting physician, leading to possible ischemia of the hand. With the growing use of radial forearm flaps, the surgeon needs to be aware of its presence during surgery and be able to adapt the procedure accordingly. The aims of the study focus on the incidence and calibre of the SUA. Ninety-five cadaveric limbs were dissected and the calibre of the different arteries measured. Four SUAs (4.2%) were found, all in male cadavers. Two of these were from the same cadaver. Measurements of the calibre of the vessels showed that the SUA was smaller than the ulnar artery. Of the limbs dissected, 4.2% had an SUA, which is a similar prevalence to other studies in Western Europe. It is most commonly found in males, unilaterally and in the right upper limb. It is extremely rare to experience consequences from intra-arterial cannulation and the SUA may have more of a beneficial role in reconstructive fasciocutaneous forearm flaps.

Vancomycin and teicoplanin use in Victorian hospitals. The Victorian Drug Usage Evaluation Group.

OBJECTIVE: To determine patterns of prescribing of glycopeptide antibiotics (vancomycin and teicoplanin) in Victorian hospitals and identify areas for targeted intervention. DESIGN: A concurrent, observational, multisite evaluation of drug use. SETTING: Thirty-five Victorian hospitals, 1-14 September 1997. STUDY POPULATION: Patients commencing a glycopeptide antibiotic course. MAIN OUTCOME MEASURES: Rate of glycopeptide antibiotic use; indications; duration of use; main hospitals using glycopeptide antibiotics. RESULTS: 293 patients (269 adults and 24 neonates) commenced on 302 glycopeptide antibiotic courses: 296 intravenous (i.v.) vancomycin courses and three each of oral vancomycin and parenteral teicoplanin. The overall rate of use was 10.3 courses per 1000 inpatient separations. Of 271 i.v. vancomycin courses for adults, 176 (65%) were for treatment--120 empirically. The median duration of treatment courses was 4.7 days (interquartile range, 2.0-8.2 days). A flucloxacillin-resistant organism was confirmed for 44% of treatment courses. Ninety-five i.v. vancomycin courses were for prophylaxis, including for cardiac (54%) and vascular surgery (21%); 82% of prophylactic courses were administered for less than 24 hours. Of all the glycopeptide antibiotic courses, 69% were administered at five major metropolitan hospitals. CONCLUSIONS: Glycopeptide antibiotic use in Victoria is concentrated in the major metropolitan hospitals. Prolonged durations of vancomycin therapy, including for surgical prophylaxis and empirical therapy not subsequently confirmed by microbiology findings, would be suitable targets for interventional strategies.