MR-guided HDR prostate brachytherapy with teleoperated steerable needles.

Conformity of tumour volumes and dose plans in prostate brachytherapy (BT) can be constrained by unwanted needle deflections, needle access restrictions and visualisation limitations. This work validates the feasibility of teleoperated robotic control of an active steerable needle using magnetic resonance (MR) for guidance. With this system, perturbations can be counteracted and critical structures can be circumvented to access currently inaccessible areas. The system comprises of (1) a novel steerable needle, (2) the minimally invasive robotics in an MR environment (MIRIAM) system, and (3) the daVinci Research Kit (dVRK). MR scans provide visual feedback to the operator controlling the dVRK. Needle steering is performed along curved trajectories to avoid the urethra towards targets (representing tumour tissue) in a prostate phantom with a targeting error of 1.2 ± 1.0 mm. This work shows the potential clinical applicability of active needle steering for prostate BT with a teleoperated robotic system in an MR environment.

Axially rigid steerable needle with compliant active tip control.

Steerable instruments allow for precise access to deeply-seated targets while sparing sensitive tissues and avoiding anatomical structures. In this study we present a novel omnidirectional steerable instrument for prostate high-dose-rate (HDR) brachytherapy (BT). The instrument utilizes a needle with internal compliant mechanism, which enables distal tip steering through proximal instrument bending while retaining high axial and flexural rigidity. Finite element analysis evaluated the design and the prototype was validated in experiments involving tissue simulants and ex-vivo bovine tissue. Ultrasound (US) images were used to provide visualization and shape-reconstruction of the instrument during the insertions. In the experiments lateral tip steering up to 20 mm was found. Manually controlled active needle tip steering in inhomogeneous tissue simulants and ex-vivo tissue resulted in mean targeting errors of 1.4 mm and 2 mm in 3D position, respectively. The experiments show that steering response of the instrument is history-independent. The results indicate that the endpoint accuracy of the steerable instrument is similar to that of the conventional rigid HDR BT needle while adding the ability to steer along curved paths. Due to the design of the steerable needle sufficient axial and flexural rigidity is preserved to enable puncturing and path control within various heterogeneous tissues. The developed instrument has the potential to overcome problems currently unavoidable with conventional instruments, such as pubic arch interference in HDR BT, without major changes to the clinical workflow.

Comment on: "A novel approach to peatlands as archives of total cumulative spatial pollution loads from atmospheric deposition of airborne elements complementary to EMEP data: Priority pollutants (Pb, Cd, Hg)" by Ewa Miszczak, Sebastian Stefaniak, Adam Michczynski, Eiliv Steinnes and Irena Twardowska.

A recent paper by Miszczak et al. (2020) examines metal contamination of mires in Poland and Norway. The authors conclude that lead (Pb) records in ombrotrophic peatlands cannot be used to reconstruct the chronological history of anthropogenic activities due to post-depositional mobility of the metal. We contest this general conclusion which stands in contrast with a significant body of literature demonstrating that Pb is largely immobile in the vast majority of ombrotrophic peatlands. Our aim is to reaffirm the crucial contribution that peat records have made to our knowledge of atmospheric Pb contamination. In addition, we reiterate the necessity of following established protocols to produce reliable records of anthropogenic Pb contamination in environmental archives.

Beta 2 integrin engagement triggers actin polymerization and phosphatidylinositol trisphosphate formation in non-adherent human neutrophils.

Beta 2 integrins are involved in the adhesion of leukocytes to other cells and surfaces. Although adhesion is required for cell locomotion, little is known regarding the way beta 2 integrin-receptors affect the actin network in leukocytes. In the present study filamentous actin (F-actin) levels in non-adherent human neutrophils have been measured by phalloidin staining after antibody cross-linking of beta 2 integrins. Antibody engagement of beta 2 integrins resulted in a rapid and sustained (146 and 131% after 30 and 300 s, respectively) increase in the neutrophil F-actin content. This is in contrast to stimulation with N-formyl-l-methionyl-l-leucyl-l-phenylalanine (fMLP), which causes a prompt and pronounced but rapidly declining rise in F-actin (214 and 127% after 15 and 300 s, respectively). Priming neutrophils with 1 nM PMA, a low concentration that did not influence the F-actin content per se, increased the magnitude of the beta 2 integrin-induced response but had no effect on the kinetics (199% after 30 s and 169% after 300 s). Removal of extracellular Ca2+ only marginally affected the beta 2 integrin-induced F-actin response for cells that were pretreated with PMA whereas the response for nonprimed cells was reduced by half. This suggests that even though extracellular Ca2+ has a modulatory effect it is not an absolute requirement for beta 2 integrin-induced actin polymerization. beta 2 integrin engagement did not affect the resting cellular level of cAMP arguing against a role of cAMP in beta 2 integrin-induced actin assembly.(ABSTRACT TRUNCATED AT 250 WORDS)

A nonpeptidyl mimic of superoxide dismutase with therapeutic activity in rats.

Many human diseases are associated with the overproduction of oxygen free radicals that inflict cell damage. A manganese(II) complex with a bis(cyclohexylpyridine)-substituted macrocyclic ligand (M40403) was designed to be a functional mimic of the superoxide dismutase (SOD) enzymes that normally remove these radicals. M40403 had high catalytic SOD activity and was chemically and biologically stable in vivo. Injection of M40403 into rat models of inflammation and ischemia-reperfusion injury protected the animals against tissue damage. Such mimics may result in better clinical therapies for diseases mediated by superoxide radicals.

Differential scanning calorimetric study of 5-enolpyruvoyl shikimate-3-phosphate synthase and its complexes with shikimate-3-phosphate and glyphosate: irreversible thermal transitions.

The thermal denaturation of native Escherichia coli 5-enolpyruvoyl shikimate-3-phosphate (EPSP) synthase, its binary complex with shikimate-3-phosphate (S3P) and its ternary complex with S3P and glyphosate have been studied using highly-sensitive differential scanning calorimetry (DSC). All observed transitions are strongly scanning-rate-dependent and irreversible. Consistent with these observations, the data were better fit by a simple irreversible model than by the controversial reversible model more commonly employed. The results obtained provide additional support for the application of irreversible models to the thermal denaturation of proteins. The calculated parameters, activation energy (Ea), enthalpy of denaturation (delta H) and transition temperature (Tm), obtained from fitting to an irreversible model agree well with values obtained from approximation techniques. Further, the results show that the formation of the ternary complex greatly enhances the thermal stability of the enzyme (delta Tm = 10.6 degrees C), while the binding of S3P alone increases the transition temperature only slightly (delta Tm = 3 degrees C). The heat of binding calculated at the transition temperature also demonstrates the greater stability of the ternary complex (delta H = -70 kcal/mol) versus the binary complex (delta H = -10 kcal/mol).

The discovery of new cholesteryl ester transfer protein inhibitors.

Cholesteryl ester transfer protein (CETP) has been an important but controversial target for elevating HDLc (high density lipoprotein cholesterol) and treating atherosclerosis. Significant progress toward inhibiting CETP has occurred on several fronts, including the development of an antisense inhibitor, irreversible small molecule inhibitors and reversible small molecule inhibitors. Several orally bioavailable, small molecule CETP inhibitors have shown potential to improve the HDLc to LDLc (low density lipoprotein cholesterol) ratio in various animal models at reasonable doses, and one of these compounds has shown efficacy in preventing atherosclerosis in a rabbit model. However, several more years of clinical testing will likely be needed to demonstrate that these clinical candidates can provide a potential therapeutic benefit to patients with coronary artery disease.

Novel biologically active nonpeptidic inhibitors of myristoylCoA:protein N-myristoyltransferase.

A new class of biologically active nonpeptidic inhibitors of Candida albicans NMT has been synthesized starting from the octapeptide ALYASKLS-NH2 (2). The synthetic strategy entailed the preparation of novel protected Ser-Lys mimics 9 and 12 from (S)- or (R)-3-iodotyrosine and then grafting key enzyme recognition elements in a stepwise manner. Like 2, compounds 16, 17, and 18 are competitive Candida NMT inhibitors that bind to the peptide recognition site of the enzyme. Moreover, 16-18 have an affinity comparable to that of 2 even though they are devoid of peptide bonds. In contrast to 2, these nonpeptidic inhibitors exhibit antifungal activity.

Design and synthesis of novel imidazole-substituted dipeptide amides as potent and selective inhibitors of Candida albicans myristoylCoA:protein N-myristoyltransferase and identification of related tripeptide inhibitors with mechanism-based antifungal activity.

A new class of antifungal agents has been discovered which exert their activity by blockade of myristoylCoA: protein N-myristoyltransferase (NMT; EC 2.1.3.97). Genetic experiments have established that NMT is needed to maintain the viability of Candida albicans and Cryptococcus neoformans,the two principal causes of systemic fungal infections in immunocompromised humans. Beginning with a weak octapeptide inhibitor ALYASKLS-NH2 (2, Ki = 15.3 +/- 6.4 microM), a series of imidazole-substituted Ser-Lys dipeptide amides have been designed and synthesized as potent and selective inhibitors of Candida albicans NMT. The strategy that led to these inhibitors evolved from the identification of those functional groups in the high-affinity octapeptide substrate GLYASKLS-NH2 1a necessary for tight binding, truncation of the C-terminus, replacement of the four amino acids at the N-terminus by a spacer group, and substitution of the glycine amino group with an N-linked 2-methylimidazole moiety. Initial structure-activity studies led to the identification of 31 as a potent and selective peptidomimetic inhibitor with an IC50 of 56 nM and 250-fold selectivity versus human NMT. 2-Methylimidazole as the N-terminal amine replacement in combination with a 4-substituted phenacetyl moiety imparts remarkable potency and selectivity to this novel class of inhibitors. The (S,S) stereochemistry of serine and lysine residues is critical for the inhibitory activity, since the (R,R) enantiomer 40 is 10(3)-fold less active than the (S,S) isomer 31. The inhibitory profile exhibited by this new class of NMT ligands is a function of the pKa of the imidazole substituent as illustrated by the benzimidazole analog 35 which is about 10-fold less potent than 31. The measured pKa (7.1 +/- 0.5) of 2-methylimidazole in 31 is comparable with the estimated pKa (approximately 8.0) of the glycyl residue in the high-affinity substrate 1a. Groups bulkier than methyl, such as ethyl, isopropyl, or iodo, at the imidazole 2-position have a detrimental effect on potency. Further refinement of 31 by grafting an alpha-methyl group at the benzylic position adjacent to the serine residue led to 61 with an IC50 of 40 nM. Subsequent chiral chromatography of 61 culminated in the discovery of the most potent Candida NMT inhibitor 61a reported to date with an IC50 of 20 nM and 400-fold selectivity versus the human enzyme. Both 31 and 61a are competitive inhibitors of Candida NMT with respect to the octapeptide substrate GNAASARR-NH2 with Ki(app) = 30 and 27 nM, respectively. The potency and selectivity displayed by these inhibitors are dependent upon the size and orientation of the alpha-substituent. An alpha-methyl group with the R configuration corresponding to the (S)-methyl-4-alanine in 2 confers maximum potency and selectivity. Structural modification of 31 and 61 by appending an (S)-carboxyl group beta to the cyclohexyl moiety provided the less potent tripeptide inhibitors 73a and 73b with an IC50 of 1.45 +/- 0.08 and 0.38 +/- 0.03 microM, respectively. However, these tripeptides (73a and 73b) exhibited a pronounced selectivity of 560- and 2200-fold versus the human NMT. More importantly 73a displayed fungistatic activity against C albicans with an EC50 of 51 +/- 17 microM in cell culture. Compound 73b also exhibited a similar antifungal activity. An Arf protein gel mobility shift assay for monitoring intracellular myristoylation revealed that a single dose of 200 microM of 73a or 73b produced < 50% reduction in Arf N-myristoylation, after 24 and 48 h, consistent with their fungistatic rather than fungicidal activity. In contrast, the enantiomer 73d which had an IC50 > 1000 microM against C. albicans NMT did not exhibit antifungal activity and produced no detectable reduction in Arf N-myristoylation in cultures of C. albicans. These studies confirm that the observed antifungal activity of 73a and 73b is due to the attenuation of NMT activity and that NMT represents an attractive tar

Conformationally constrained [p-(omega-aminoalkyl)phenacetyl]-L-seryl-L-lysyl dipeptide amides as potent peptidomimetic inhibitors of Candida albicans and human myristoyl-CoA:protein N-myristoyl transferase.

MyristoylCoA:protein N-myristoyltransferase (NMT) covalently attaches the 14-carbon saturated fatty acid myristate, via an amide bond, to the N-terminal glycine residues of a variety of cellular proteins. Genetic studies have shown that NMT is essential for the viability of the principal fungal pathogens which cause systemic infection in immunosuppressed humans and hence is a target for development of fungicidal drugs. We have generated a class of potent peptidomimetic inhibitors of the NMT from one such fungal pathogen, Candida albicans. The N-terminal tetrapeptide from a substrate analog inhibitor, ALYASKL-NH2, was replaced with an omega-aminoalkanoyl moiety having an optimal 11-carbon chain for inhibition (11-aminoundecanoyl-SKL-NH2, 3a, IC50 = 1.2 +/- 0.14 microM). A series of replacements for the C-terminal Leu established that residues containing a lipophilic side chain were most effective, with cyclohexylalanine having the greatest potency (3g, IC50 = 0.36 +/- 0.06 microM). Removal of the carboxamide moiety led to a metabolically stable dipeptide inhibitor containing an N-(cyclohexylethyl)lysinamide (17e, IC50 = 0.11 +/- 0.03 microM). Partial rigidification of the flexible aminoundecanoyl chain produced the dipeptide p-(omega-aminohexyl)phenacetyl-L-seryl-L-lysyl-N-(cyclohexyleth yl)amide (26b, IC50 = 0.11 +/- 0.04 microM). Subsequent incorporation of an alpha-methyl substituent into 26b provided the dipeptide analog [2-[p-(omega-aminohexyl)phenyl]propionyl]-L-seryl-L-lysyl-N-(cyclohex ylethyl)amide, a very potent inhibitor (48, IC50 = 0.043 +/- 0.006 microM), which retained the three essential elements required for recognition by the acyl transferase's peptide binding site.

Analysis of genotypic diversity and relationships among Pseudomonas stutzeri strains by PCR-based genomic fingerprinting and multilocus enzyme electrophoresis.

Molecular fingerprinting procedures including random amplified polymorphic DNA-PCR (RAPD), repetitive extragenic palindromic PCR (rep-PCR) with REP, ERIC, and BOX primers and multilocus enzyme electrophoresis (MLEE) were used for genotypic characterization of 16 P. stutzeri strains originally isolated from marine, waste water, clinical and soil samples. A distinct genotype of each strain and overall great genotypic diversity were found within P. stutzeri. Cluster analysis (UPGMA) of the electrophoretic patterns of all PCR-based methods used resulted in concordant grouping of 8 strains. With the other strains conflicting clustering was noticed. The variability of clustering in PCR-based analyses suggested the occurrence of chromosomal rearrangements. When RAPD-, rep-PCR and MLEE fingerprints were used in a cluster analysis of combined electrophoretic patterns, the P. stutzeri strains could be differentiated into seven distinct genotypic groups. These results supported the subdivision of the species in several genomovars and reproduced, with higher resolution, the strain grouping after 16S rRNA phylogenetic reconstruction. The combined use of several fingerprint-based genotypic analyses results in higher resolutive strain clustering by UPGMA than each of the single ones analyzed separately. Additionally, this combination of individual typings proved to be reliable of the determination of the great genotypic diversity and relationships among the P. stutzeri strains.

Prevalence of breastfeeding at four months in general practices in south London.

BACKGROUND: Successive quinquennial National Infant Feeding Surveys have provided a valuable picture of national and regional variations in infant feeding practices within the United Kingdom. Social variation in breastfeeding has been recognised to be an important source of health inequalities in childhood by the Independent Inquiry into Inequalities in Health Report. AIM: To determine the prevalence of breastfeeding at birth and at four months in a sample of women from urban general practices, its variation between practices, and relation to practice population deprivation scores. To report the timing of introduction of solid feeds. DESIGN OF STUDY: Cross-sectional questionnaire survey based on a random cluster sample. SETTING: Women with infants aged four months in general practices in South London. METHOD: Mode of infant feeding at birth and four months, and time of introduction of solids. Jarman score as a measure of practice population deprivation. Housing tenure, maternal ethnic group, and maternal age at leaving full-time education. RESULTS: Twenty-five general practices were sampled. Median practice Jarman score was 15.0 (interquartile range [IQR] = 12.6-21.9). Responses were received from 1053 out of 1532 mothers approached (69%). Of these, 87% (897) had breastfed at birth, while 59% (609) were still breastfeeding their babies at four months. Mothers in rented accommodation were less likely to breastfeed than owner-occupiers (odds ratio [95% CI] = 0.52 [0.37-0.74]), as were women of white, compared with those of black, ethnic origin (odds ratio [95% CI] = 0.55 [0.36-0.82]). Those who completed up to two years and more than two years education after the age of 16 were 2.94 (95% CI = 1.85-4.66) and 9.25 (95% CI = 6.02-14.21) more likely to breastfeed at four months, respectively, than mothers whose formal education was completed at or before 16 years. Practice-specific rates of breastfeeding ranged from 71% to 100% at birth (median 87%; IQR = 79-93%) and 22% to 83% at four months (median 61%; interquartile range = 47-66%). The intra-practice correlation coefficient for breastfeeding at four months was 0.052 (within-cluster variance = 0.23, between-cluster variance = 0.013). There was no association between breastfeeding at four months and practice-specific Jarman score. Median age of starting solids was 16 weeks (IQR = 15-17 weeks). CONCLUSIONS: Housing tenure, maternal education, and ethnic group are significantly associated with breastfeeding prevalence at four months. Between-practice variation in breastfeeding prevalence is not associated with measures of practice population deprivation, as assessed by Jarman scores. Consideration should be given to including information on maternal ethnic group and housing tenure in future National Infant Feeding Surveys. Current weaning practices fall short of the recommendation of the World Health Assembly.

Support for breastfeeding mothers.

BACKGROUND: Exclusive breastfeeding rates at three to four months remain low in many health care settings. In economically advantaged countries, young mothers, those in low-income groups or those who ceased full-time education at an early age are least likely to breastfeed. In poorer countries, more affluent groups may breastfeed less. OBJECTIVES: The objective of this review was to assess the effects of breastfeeding support. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register (last searched March 1998), Medline (from 1993), Embase (from 1980), Cinahl, Midirs (from 1991), English National Health Board database and reference lists of articles. We contacted researchers in the field. SELECTION CRITERIA: Controlled trials of acceptable quality comparing extra support for breastfeeding mothers with usual maternity care. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by the second reviewer. MAIN RESULTS: Thirteen trials were included. The relative risk for stopping exclusive feeding within two months was 0. 83, 95% confidence interval 0.72 to 0.96. The relative risk for stopping breastfeeding within two months was 0.74, 95% confidence interval 0.65 to 0.86. One more mother will breastfeed for two months if support is provided for nine women (95% confidence interval 6 to 21). Similarly, one more woman will breastfeed exclusively if support is given to nine women (95% confidence interval 6 to 40). REVIEWER'S CONCLUSIONS: The provision of extra support by professionals with special skills in breastfeeding appears to result in more mothers breastfeeding their babies until two months of age, and more mothers breastfeeding their babies exclusively to two months of age.

Support for breastfeeding mothers.

BACKGROUND: Both observational and recent experimental evidence support the promotion of breastfeeding as the optimal form of infant nutrition. There is, however, uncertainty as to the most effective way of providing support to women who choose to breastfeed their children. A systematic review was performed to describe studies undertaken in this area and to assess the effectiveness of supplementary support. OBJECTIVES: The objective of this review was to assess the effects of breastfeeding support. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, MEDLINE and EMBASE. These were last searched in March 2001. Secondary references were searched and researchers in the field were contacted. SELECTION CRITERIA: Controlled trials of acceptable quality comparing extra support for breastfeeding mothers with usual maternity care. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second reviewer. MAIN RESULTS: Twenty eligible randomised or quasi-randomised controlled trials from 10 countries were identified involving 23,712 mother-infant pairs. There was a beneficial effect on the duration of any breastfeeding in the meta-analysis of all forms of extra support (relative risk (RR) for stopping any breastfeeding before six months 0.88 [95% confidence interval (CI) 0.81,0.95]; 15 trials, 21,910 women). The effect was greater for exclusive breastfeeding (RR 0.78 [95% CI 0.69,0.89]; 11 trials, 20,788 women). Extra professional support appeared beneficial for any breastfeeding (RR 0.89 [95% CI 0.81,0.97]; 10 trials, 19,696 women) and for exclusive breastfeeding (RR 0.90 [95% confidence interval 0.81,1.01]; six trials, 18,258 women) although the latter effect did not achieve full statistical significance. Lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66 [95% CI 0.49,0.89]; five trials, 2530 women) but its effect on any breastfeeding did not reach statistical significance (RR 0.84 [95% CI 0.69,1.02]; five trials, 2224 women). Professional support in the largest trial to assess health outcomes produced a significant reduction in the risk of gastro-intestinal infections and atopic eczema. In two trials with children suffering from diarrhoeal illness extra support was highly effective in increasing short term exclusive breastfeeding rates and reducing recurrence of diarrhoea. REVIEWER'S CONCLUSIONS: Consideration should be given to providing supplementary breastfeeding support as part of routine health service provision. There is clear evidence for the effectiveness of professional support on the duration of any breastfeeding although the strength of its effect on the rate of exclusive breastfeeding is uncertain. Lay support is effective in promoting exclusive breastfeeding while the strength of its effect on the duration of any breastfeeding is also uncertain. Evidence supports the promotion of exclusive breastfeeding as central to the management of diarrhoeal illness in partially breastfed infants. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings - in particular in those communities with low rates of breastfeeding initiation. Research is also required into the most appropriate training for those, whether lay or professional, who support breastfeeding mothers.

A rationalized approach to physiotherapy for low-back pain.

A systematic approach to low-back pain is presented that relies on the classification of patients according to their symptoms. Rational systems of physiotherapy are proposed for each group and incorporated into an algorithmn. One hundred forty-two patients with mechanical low-back pain have been treated, and their response has been assessed by means of a postal questionnaire. Patients were offered an educational program, exercises, spinal manipulation, spinal supports, and analgesic medication. Eighteen percent of patients became completely free of pain, and 59% experienced a reduction in pain level. The most effective treatment was education in back care, followed closely by an exercise program. The responses were different in the various subgroups, and a series of revised flow charts is presented.

Computer-assisted revision total knee replacement.

A technique for performing allograft-augmented revision total knee replacement (TKR) using computer assistance is described, on the basis of the results in 14 patients. Bone deficits were made up with impaction grafting. Femoral grafting was made possible by the construction of a retaining wall or dam which allowed pressurisation and retention of the graft. Tibial grafting used a mixture of corticocancellous and morsellised allograft. The position of the implants was monitored by the computer system and adjusted while the cement was setting. The outcome was determined using a six-parameter, quantitative technique (the Perth CT protocol) which measured the alignment of the prosthesis and provided an objective score. The final outcomes were not perfect with errors being made in femoral rotation and in producing a mismatch between the femoral and tibial components. In spite of the shortcomings the alignments were comparable in accuracy with those after primary TKR. Computer assistance shows considerable promise in producing accurate alignment in revision TKR with bone deficits.

Venous thrombosis produced by the local injection of fat.

An experimental study performed in 16 mongrel dogs is presented, which shows that when venous stasis is combined with the local injection of non-esterified fatty acid an intense thrombosis results. This response is not produced by venous stasis alone, nor by the combination of venous stasis and triacylglycerol. Histologically it is quite different from the response produced by an inert intraluminal foreign body. It does resemble venous thrombosis described experimentally and in patients. The clinical relevance of these findings is that during accidental or operative trauma to a long bone, fat is commonly forced into the local venous circulation. If this event is combined with venous stasis or a tourniquet is used, then the circumstances of this experiment are reproduced. It is suggested that the venous thrombosis which commonly complicates long-bone injury or operation is in part caused by the thrombogenic nature of the introduced fat.

Systemic disturbance from Thompson's arthroplasty: a age-matched and sex-matched controlled retrospective survey.

The records of 107 patients with displaced subcaptial hip fractures treated by Thompson's femoral head replacements have been reviewed to determine the mortality and certain aspects of systemic morbidity. Comparison was made with a group, matched exactly for age and sex, in which intertrochanteric fractures were treated by nail-plate fixation. The patients treated by Thompson's arthroplasty were further subdivided into two groups: one in which methylacrylic cement was used, and one in which it was not used. We found no difference in the mortality of the patients undergoing replacement arthroplasty and nail-plate fixation. Similarly there was no difference in the incidence of cerebrovascular incidents and myocardial infarction after operation. There was a higher incidence of transient cardiac failure following Thompson's arthroplasty. Hypotension during the operation occurred irrespective of whether cement was used; nor was the use of cement associated with increased mortality. However, it seems that methylacrylic cement does contribute to the cardiac failure that may occur after Thompson's arthroplasty.

Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur. A prospective randomised study.

A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of 70 years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients.

The importance of femoral rotation in chondromalacia patellae as shown by serial radiography.

A new radiological technique is presented in which serial axial radiographs of the patellofemoral joints are taken under conditions in which the muscles about the knee and hip are contracted in a manner similar to that during weight-bearing. A form of analysis has been developed whereby patellar rotation can be measured in two planes and femoral rotation about its long axis inferred. A population of asymptomatic adults and children was investigated in this way and their results (regarded as normal) compared with those in fifteen children with idiopathic chondromalacia patellae. In the normal child the femur rotates medially with the onset of muscle activity; by contrast the children with chondromalacia show a reversal of this mechanism.