Risk of extrapelvine vascular injuries in osteosynthesis with gliding hip screws.

BACKGROUND: Dynamic hip screw (DHS) osteosynthesis represents one of the most frequently performed fixation methods in orthopedic practice. The purpose of this study was to determine the potential risk of vascular damage by DHS side-plate screws (PS) and plunging instruments for individual femoral vessels and screw positions. METHODS: In ten hemipelvic/leg specimens mounted with a large femur distractor, a DHS system with a four-hole side-plate was inserted. PS were inserted in 3 consecutive courses with different inclinations in the frontal plane of 0° (group 1), - 30° posterior (group 2) and + 30° anterior (group 3) in relation to the side-plate's surface, resulting in 120 PS positions. After screw tightening, the soft tissues on the medial side of the femur were dissected and investigated for vascular compromise; in each course, the effect of overshot instruments within a range of 50 mm beyond the side-plate's surface was also tested. RESULTS: Totally, 37/120 screw positions (31%) revealed potential vascular compromise which comprised of 15/120 (13%) direct hits by screw tips and 22/120 (18%) potential impacts by plunging instruments. The deep femoral artery system (DFA) was significantly (p = 0.007) most often affected but no significant differences for individual vascular structures were seen. Direct vascular impacts occurred significantly more often (p = 0.0047) in screws with 0° inclination compared to + 30° inclination (p = 0.017). Significant differences among individual screw positions were only found in group - 30° with direct vessel contacts (p = 0.038). CONCLUSIONS: The DFA system is significantly more at risk while significant preference of a certain vessel is missing. Our data indicate that more than 30% of 120 screw positions in DHS osteosynthesis revealed a potential danger of vascular compromise, when surgical principles are denied in hip fracture fixation. CLINICAL RELEVANCE: Though vascular complications are infrequently encountered in DHS osteosynthesis they have to be considered as a potential complication when surgical principles are not followed in this anatomic area.

Isotensor Dibaryon in the pp→ppπ

Exclusive measurements of the quasifree pp→ppπ^{+}π^{-} reaction have been carried out at WASA@COSY by means of pd collisions at T_{p}=1.2 GeV. Total and differential cross sections have been extracted covering the energy region T_{p}=1.08-1.36 GeV, which is the region of N^{*}(1440) and Δ(1232)Δ(1232) resonance excitations. Calculations describing these excitations by t-channel meson exchange are at variance with the measured differential cross sections and underpredict substantially the experimental total cross section. An isotensor ΔN dibaryon resonance with I(J^{P})=2(1^{+}) produced associatedly with a pion is able to overcome these deficiencies.

Spin Dependence of η Meson Production in Proton-Proton Collisions Close to Threshold.

Taking advantage of the high acceptance and axial symmetry of the WASA-at-COSY detector, and the high polarization degree of the proton beam of COSY, the reaction p[over →]p→ppη has been measured close to threshold to explore the analyzing power A_{y}. The angular distribution of A_{y} is determined with the precision improved by more than 1 order of magnitude with respect to previous results, allowing a first accurate comparison with theoretical predictions. The determined analyzing power is consistent with zero for an excess energy of Q=15 MeV, signaling s-wave production with no evidence for higher partial waves. At Q=72 MeV the data reveal strong interference of Ps and Pp partial waves and cancellation of (Pp)^{2} and Ss^{*}Sd contributions. These results rule out the presently available theoretical predictions for the production mechanism of the η meson.

Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017.

Therapeutic drug monitoring (TDM) is the quantification and interpretation of drug concentrations in blood to optimize pharmacotherapy. It considers the interindividual variability of pharmacokinetics and thus enables personalized pharmacotherapy. In psychiatry and neurology, patient populations that may particularly benefit from TDM are children and adolescents, pregnant women, elderly patients, individuals with intellectual disabilities, patients with substance abuse disorders, forensic psychiatric patients or patients with known or suspected pharmacokinetic abnormalities. Non-response at therapeutic doses, uncertain drug adherence, suboptimal tolerability, or pharmacokinetic drug-drug interactions are typical indications for TDM. However, the potential benefits of TDM to optimize pharmacotherapy can only be obtained if the method is adequately integrated in the clinical treatment process. To supply treating physicians and laboratories with valid information on TDM, the TDM task force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) issued their first guidelines for TDM in psychiatry in 2004. After an update in 2011, it was time for the next update. Following the new guidelines holds the potential to improve neuropsychopharmacotherapy, accelerate the recovery of many patients, and reduce health care costs.

Minimal Invasive Dorsal Plate Osteosynthesis of the Tibia--Are Nerves and Vessels at Risk? An Anatomical Study.

PURPOSE OF THE STUDY: Purpose of this anatomic study was to develop a new and safe technique of minimal invasive dorsal plate osteosynthesis for tibia shaft fractures. MATERIAL AND METHODS: Sixteen paired adult lower limbs of eight different cadaveric specimens were examined. Anatomical prebending for each plate was done. Plates were inserted percutaneously, following plate fixation the neurovascular bundle was dissected out. The distance between the neurovascular bundle (posterior tibial nerve, posterior tibial artery) and the plate was measured at two different positions. The distance to the origin of the flexor digitorum longus muscle and the arch of the soleus muscle was measured. RESULTS: The mean distance between the neurovascular bundle and the plate amounted 1.4 cm (±0,2 cm; 1.0-1.7 cm) at hole number six and 1.1 cm (±0.4 cm; 0.6-2.0 cm) at hole number ten. The nerve was never directly in contact with the plate. The flexor digitorum longus muscle had its origin along the plate and was between the plate and the neurovascular bundle in all cases. CONCLUSIONS: Dorsal percutaneous plate insertion is a safe and easy method for osteosyntesis of tiba shaft fractures. Especially in case of poor skin and soft tissue conditions this technique offers a good alternative.

The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study.

PURPOSE OF THE STUDY: Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of this study was to analyze structures that are at risk during this approach. MATERIAL AND METHODS: Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP anterolateral distal tibial plates were percutaneously inserted according to the recommended technique. Dissection was performed to examine the relation of the superficial and deep peroneal nerves and anterior tibial artery relative to the plate. RESULTS: The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In one specimen, a significant branch of the deep peroneal nerve was found to be entrapped under the plate. CONCLUSION: Caution is advised when using anterolateral minimally invasive technique for plate insertion and screw placement in the distal tibia due to great variability in the neurovascular structures that course distally in the lower leg and cross the ankle.

Abashian-Booth-Crowe effect in basic double-pionic fusion: a new resonance?

We report on an exclusive and kinematically complete high-statistics measurement of the basic double-pionic fusion reaction pn→dπ(0)π(0) over the full energy region of the ABC effect, a pronounced low-mass enhancement in the ππ-invariant mass spectrum. The measurements, which cover also the transition region to the conventional t-channel ΔΔ process, were performed with the upgraded WASA detector setup at COSY. The data reveal the Abashian-Booth-Crowe effect to be uniquely correlated with a Lorentzian energy dependence in the integral cross section. The observables are consistent with a narrow resonance with m=2.37 GeV, Γ≈70 MeV and I(J(P))=0(3(+)) in both pn and ΔΔ systems. Necessary further tests of the resonance interpretation are discussed.

Trends in the use of radiotherapy and radical surgery for patients with bladder urothelial cell carcinoma in East Anglia, 1995-2006.

OBJECTIVE: • To examine the use of radiotherapy and radical surgery for bladder urothelial cell carcinoma (UCC) before, during and after national initiatives for reorganization of uro-oncology services. PATIENTS AND METHODS: • Population-based data (1995-2006) from a cancer registry with stable coding practices were analysed. • Bladder UCC was defined using relevant International Classification of Disease site and morphology codes. • Time trends in the use of radiotherapy and radical surgery, and other predictors of their use were examined. RESULTS: • Of 4639 bladder UCC patients aged ≥40 years (76% men), stage information was available for 4303 (93%). • Morphology and stage case mix remained stable during the study period. • Radiotherapy use decreased significantly (from 31% in 1995-1998 to 22% in 2003-2006, P < 0.001) among patients of any stage, whilst radical surgery use increased significantly (from 8 to 13%, P < 0.001), particularly among stage II-IV patients. • The proportion of patients treated by both radiotherapy and surgery also decreased notably (from 4.0 to 1.1%). • Women were significantly more likely to present in stages II-IV [odds ratio (OR) = 1.22, 95% confidence interval (CI) = 1.06-1.40, P = 0.005], and less likely to be treated with radiotherapy (OR = 0.84, 95% CI: 0.72-0.99, P = 0.036). CONCLUSIONS: • Use of radical surgery in UCC invading bladder muscle increased and use of radiotherapy decreased during the study period, most probably reflecting the increasing availability of specialist surgical management. Sociodemographic variation in treatment was limited to lower use of radiotherapy in women. • Further research should encompass treatment timeliness and other aspects of care quality, as well as exploring potential differences in endoscopic treatments for disease not invading bladder muscle.

GaN epitaxial layers prepared on nano-patterned Si(001) substrate.

We report the growth of GaN epitaxial layer on Si(001) substrate with nano-patterns prepared by dry etching facility used in integrated circuit (IC) industry. It was found that the GaN epitaxial layer prepared on nano-patterned Si(001) substrate exhibits both cubic and hexagonal phases. It was also found that threading dislocation observed from GaN prepared on nano-patterned Si(001) substrate was significantly smaller than that prepared on conventional unpatterned Si(111) substrate. Furthermore, it was found that we can reduce the tensile stress in GaN epitaxial layer by about 78% using the nano-patterned Si(001) substrate.

Cathodoluminescence studies of GaAs nano-wires grown on shallow-trench-patterned Si.

The optical properties of GaAs nano-wires grown on shallow-trench-patterned Si(001) substrates were investigated by cathodoluminescence. The results showed that when the trench width ranges from 80 to 100 nm, the emission efficiency of GaAs can be enhanced and is stronger than that of a homogeneously grown epilayer. The suppression of non-radiative centers is attributed to the trapping of both threading dislocations and planar defects at the trench sidewalls. This approach demonstrates the feasibility of growing nano-scaled GaAs-based optoelectronic devices on Si substrates.

Population-based prostate-specific antigen testing in the UK leads to a stage migration of prostate cancer.

OBJECTIVE: To determine, within the UK, the stage and grade of prostate cancers that would be found through population-based prostate specific antigen (PSA) testing and biopsy. SUBJECTS AND METHODS: In the 'Prostate Testing for Cancer and Treatment' trial (ProtecT), men aged 50-69 years were recruited from nine cities in the UK and from randomly selected practices of general practitioners. Those with a PSA level of >3 ng/mL were offered a prostate biopsy. Age, PSA, stage and grade at diagnosis of ProtecT participants with cancer were compared with contemporaneous incident cases aged 50-69 years (age-restricted Cancer Registry cases) registered with the Eastern Cancer Registration and Information Centre (ECRIC). RESULTS: Within ProtecT, 94,427 men agreed to be tested (50% of men contacted), 8807 ( approximately 9%) had a raised PSA level and 2022 (23%) had prostate cancer; 229 ( approximately 12%) had locally advanced (T3 or T4) or metastatic cancers, the rest having clinically localized (T1c or T2) disease. Within ECRIC, 12,661 cancers were recorded over the same period; 3714 were men aged 50-69 years at diagnosis. Men in ProtecT had a lower age distribution and PSA level, and the cancers were of lower stage and grade (P < 0.001 for all comparisons). If population-based PSA testing were introduced in the UK, approximately 2660 men per 100,000 aged 50-69 years would be found to have prostate cancer, compared to current rates of approximately 130 per 100,000. If half of men accepted PSA testing, approximately 160,000 cancers would be found, compared to 30,000 diagnosed each year at present. CONCLUSIONS: Population-based PSA testing resulted in a significant downward stage and grade migration, and most such cancers were of low stage and grade, which could lead to risks of over-treatment for some men.

[Color-codes implementation shortens the decision-to-delivery interval of emergency C-sections]. / La mise en oeuvre des codes "couleur" réduit le délai décision-naissance des césariennes urgentes.

OBJECTIVES: To assess the efficiency of a new tool designed to shorten the decision-to-delivery interval (DDI) for emergency C-sections (CS). MATERIALS AND METHODS: DDI comparisons during three 6-month periods in a third level maternity. In stage A we evaluated the spontaneous DDI, in stage B the DDI was measured after the introduction of a color-code communication tool related to the degree of urgency for CS (amber code indicated urgent CS with an ideal DDI of 30 min and red code for very urgent CS with an ideal DDI of 15 min). In stage C we assessed the impact of the color-codes related protocols implementation. RESULTS: Two hundred and fifty-three C-sections were included (211 urgent CS and 42 very urgent CS). Mean DDI decreased significantly from 42 min to 24 min between period A and period C for amber codes (corresponding to 43.2% and 82.1% of the objectives respectively) and from 24.9 min to 10.7 min for red codes (20% et 83.3% of the objectives). CONCLUSION: This study suggests that color-codes and their related application protocols significantly shorten the DDI during the evaluation periods.

Frequency of successful intra-articular puncture of finger joints: influence of puncture position and physician experience.

OBJECTIVE: Physicians and specialists routinely perform IA punctures and injections on patients with joint injuries, chronic arthritis and arthrosis to release joint effusion or to inject drugs. The purpose of this study was to investigate the frequencies of intra- and peri-articular cannula positioning during this procedure. METHODS: A total of 300 cadaveric finger joints were injected with a methyl blue-containing solution and subsequently dissected to distinguish intra- from peri-articular injections. To assess the influence of puncture position on successful injection, half of the joints were injected dorsally and the other half dorso-radially. To assess the importance of practical experience for a positive outcome, half of the injections were performed by an inexperienced resident and half by a skilled specialist. RESULTS: The overall frequency of occurrence of peri-articular injections was much higher than expected (overall: 23%, specialist: 15%, resident: 32%) The failure rate was significantly higher than the average with the joints of the little finger and the DIP joints of each phalanx. CONCLUSIONS: Even skilled specialists cannot guarantee to insert the cannula into the joint in every case. Unintended peri-articular drug injection moreover may affect the surrounding ligaments or tendons, leading to serious complications. Correct positioning of the needle in the joint may be facilitated by fluoroscopy in doubtful cases.

The influence of lateral and anterior angulation of the proximal ulna on the treatment of a Monteggia fracture: an anatomical cadaver study.

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5 degrees (11 degrees to 23 degrees ) and the mean anterior deviation 4.5 degrees (1 degrees to 14 degrees ). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value.

Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap.

OBJECTIVE: To report our experience using two staged bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. METHODS: A retrospective study of 9417 open-heart surgery cases performed between 1998 and 2003 at The Prince Charles Hospital. Sixty-eight patients were referred to the plastic surgical team for consideration of bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. RESULTS: There was a trend for early referral for flap operation (median 10 days) (p=0.49). The median postoperative ventilation time and ICU stay were 1 and 2 days, respectively. The median hospital stay after flap operation was 15.5 days. One-year overall survival was 91%. Ninety-five per cent healed stable sternum was achieved with 100% failure in patients with chronically unstable sternum. Early referral appears to be an important factor in preventing osteomyelitis formation (p=0.05) with the longest recurrence at 10 months postoperatively. CONCLUSIONS: The key to the successful management of deep sternal wound infection is early referral for pectoralis major flap operation. Our approach is safe with good long-term outcomes. We recommend this approach in all severe deep sternal wound infection but not in patients with chronic unstable sternum.

[Amniotic fluid embolism: a review]. / Embolie de liquide amniotique: mise au point.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. It is a difficult and somewhat intangible diagnosis that warrants a high index of suspicion by physicians. AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or foetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. No laboratory test is specific to attest the diagnosis and autopsy must to be realised in case of maternal death. Although non-specific, the diagnosis of AFE could be supported by the observation of amniotic fluid in the central venous blood as well as in the bronchoalveolar fluid. This easy and quick test will be helpful in decision-making. Prompt and aggressive supportive treatment is required to lessen an otherwise dismal outcome, which may include death and permanent disability. This article provides an account of the protean clinical features, pathogenesis, and principles involved in treatment.

[Amniotic fluid embolism: successful evolution course of isolated disseminated intravascular coagulation and early biological diagnosis]. / Embolie de liquide amniotique : évolution favorable d'une CIVD isolée et diagnostic biologique précoce.

Amniotic embolism is a sudden, unexpected and devastating complication of pregnancy. The diagnosis is usually made on the basis of clinical presentation after excluding differential diagnosis or at autopsy in the event of death of the parturient. We need to develop simple, non-invasive, sensitive tests for a reliable and early diagnosis. We report the case of a 34-year-old woman, who presented soon after delivery, an isolated disseminated intravascular coagulation with severe haemorrhage, an haemostatic hysterectomy was required. A 3370 g child was delivered by caesarean section. The patient survived without sequelae. The diagnosis of amniotic embolism was established by the presence of amniotic cells in the maternal central venous blood as well as in the bronchoalveolar fluid.

[Decision-to-deliver interval for forceps delivery and cesarean section: 137 extractions for abnormal fetal heart rhythm during labor]. / Rapidité d'extraction respective des césariennes et des forceps réalisés en urgence: à propos de 137 extractions pour anomalies du rythme cardiaque foetal en cours de travail.

AIM: Comparison of the decision to delivery interval in cases of forceps delivery and in cases of cesarean sections. MATERIAL AND METHOD: A retrospective analysis was performed on 137 cases of forceps deliver (n = 63) and cesarean section (n = 74) indicated for abnormal fetal heart rhythm. All cases were observed in a level 3 maternity unit between October 2003 and August 2004. RESULTS: The mean decision-to-delivery interval was significantly shorter in the forceps group (14.84 min +/- 6.54 versus 29.31 min +/- 11.79 p < 0.0001). Maternal and neonatal morbidity were comparable. CONCLUSION: This study suggest that once the fetal head is engaged, forceps delivery can significantly reduced the decision-to-delivery interval.