Effect of combined exogenous progesterone with luteotrophic support via equine chorionic gonadotrophin (eCG) on corpus luteum development, circulating progesterone concentrations and embryo development in cattle.

The aim was to examine the effect of a single intramuscular (i.m.) injection of equine chorionic gonadotrophin (eCG) on Day 3 after oestrus on corpus luteum (CL) development, circulating progesterone and conceptus development in cross-bred beef heifers. In Experiment 1, heifers received: (1) saline, or a single i.m. injection of eCG on Day 3 at (2) 250IU (3) 500IU (4) 750IU or (5) 1000IU. Administration of eCG resulted in increased luteal tissue area and progesterone and oestradiol concentrations compared with controls. In Experiment 2, heifers received (1) a progesterone-releasing intravaginal device (PRID Delta) from Day 3 to 5 or (2) a PRID Delta from Day 3 to 5 plus a single injection of 750IU eCG on Day 3. In vitro-produced blastocysts (n=10 per recipient) were transferred on Day 7 and heifers were slaughtered on Day 14 to assess conceptus development. Administration of eCG reduced the number of short cycles (6.3% vs 31.3%) and increased mean luteal tissue weight (P=0.02). Insertion of a PRID Delta on Day 3 resulted in an elevation (P<0.05) in serum progesterone until removal on Day 5. Administration of eCG at the time of PRID Delta insertion resulted in higher progesterone levels (P<0.05) from Day 10 onwards. Conceptus dimensions were not affected. In conclusion, a single injection of eCG on Day 3 increased CL size and progesterone concentrations and, when given in conjunction with a progesterone-releasing device, appeared to reduce the number of short cycles, presumably due to its luteotrophic nature. The implications of the elevated oestradiol concentrations for embryo quality require further study.

Effect of hCG administration during corpus luteum establishment on subsequent corpus luteum development and circulating progesterone concentrations in beef heifers.

This study examined the effect of a single administration of human chorionic gonadotrophin (hCG) on Day 1 to 4 after oestrus on corpus luteum (CL) development and circulating progesterone (P4). Oestrus-synchronized heifers (n=43) were administered a single intramuscular injection of saline on Day 1 (control) or 3000IU hCG on Day 1, 2, 3 or 4 after oestrus. Administration of hCG on Day 1 had no effect on CL area, on Day 2 increased CL area from Day 6 to 12 (P<0.05), on Day 3 increased CL area from Day 9 to 11, while on Day 4 increased CL size on Days 9 and 10 (P<0.05). Administration of hCG on Day 4 induced the formation of an accessory CL in 89% of heifers, resulting in a significant increase in total luteal tissue area on the ovaries compared with all other groups. Consistent with the effects on the CL, hCG on Day 1 did not affect P4 concentrations, on Day 2 significantly increased P4 compared with the control from Day 6 to 11 (P<0.05), on Day 3 resulted in a non-significant increase in P4 while hCG on Day 4 increased P4 from Day 8 to 13 compared with the control (P<0.05). In conclusion, administration of hCG as early as Day 2 after oestrus results in increased P4 in circulation from Day 6, which should have beneficial downstream effects in terms of uterine receptivity and conceptus elongation.

Paradoxical effect of supplementary progesterone between Day 3 and Day 7 on corpus luteum function and conceptus development in cattle.

The aim of the present study was to investigate the effect of short-term progesterone (P4) supplementation during the early metoestrous period on circulating P4 concentrations and conceptus development in cattle. The oestrous cycles of cross-bred beef heifers were synchronised using a 7-day P4-releasing intravaginal device (PRID® Delta; 1.55 g P4) treatment with administration of a prostaglandin F(2α) analogue (Enzaprost; CEVA Sante Animale) the day before PRID® Delta removal. Only those heifers recorded in standing oestrus (Day 0) were used. In Experiment 1, heifers were randomly assigned to one of five groups: (1) control: no treatment; (2) placebo: insertion of a blank device (no P4) from Day 3 to Day 7; (3) insertion of a PRID® Delta from Day 3 to Day 7; (4) insertion of a PRID® Delta from Day 3 to Day 5; or (5) insertion of a PRID® Delta from Day 5 to Day 7. In vitro-produced blastocysts were transferred to each heifer in Groups 2-5 on Day 7 (n=10 blastocysts per heifer) and conceptuses were recovered when heifers were killed on Day 14. Based on the outcome of Experiment 1, in Experiment 2 heifers were artificially inseminated at oestrus and randomly assigned to one of three treatment groups: (1) placebo; (2) PRID from Day 3 to Day 5; or (3) PRID from Day 3 to Day 7. All heifers were killed on Day 16 and recovered conceptuses were incubated in synthetic oviducal fluid medium for 24 h; spent media and uterine flushes were analysed for interferon-τ (IFNT). In both experiments, daily blood samples were taken to determined serum P4 concentrations. Data were analysed using the PROC MIXED procedure of SAS (SAS Institute, Cary, NC, USA). Insertion of a PRID resulted in an increase (P<0.05) in serum P4 that declined following removal. In Experiment 1, P4 supplementation from Day 3 to Day 5 (17.0±1.4 mm) or Day 3 to Day 7 (11.3±2.3 mm) increased conceptus length compared with placebo (2.1±1.8 mm). Serum P4 was significantly lower from Day 9 to Day 14 (P<0.05) and the weight of the Day 14 corpus luteum (CL) was lower in the PRID Day 3-7 group than the placebo or control groups. In Experiment 2, supplementation from Day 3 to Day 5 (94.0±18.8 mm) or Day 3 to Day 7 (143.6±20.6 mm) increased conceptus length on Day 16 compared with placebo (50.3±17.4 mm). Serum P4 was significantly lower in the two supplemented groups following PRID removal compared with placebo (P<0.05) and was associated with a lower CL weight in the Day 3-7 group. Conceptus length was strongly correlated with the IFNT concentration in the uterine flush (r=0.58; P=0.011) and spent culture medium (r=0.68; P<0.002). The findings of the present study highlight the somewhat paradoxical effects of P4 supplementation when given in the early metoestrous period in terms of its positive effect on conceptus development and its potentially negative effects on CL lifespan.

Hospital admissions and emergency department visits for people with dementia.

BACKGROUND: Previous studies have suggested that people with dementia (PwD) are more likely to be admitted to hospital, have prolonged hospital stay, or visit an emergency department (ED), compared to people without dementia. AIM: This study assessed the rates of hospital admissions and ED visits in PwD and investigated the causes and factors predicting this healthcare use. Further, this study assessed survival following hospital admissions and ED visits. DESIGN: This was a retrospective study with data from 26 875 PwD and 23 961 controls. METHODS: Data from national datasets were extracted for demographic characteristics, transitions to care homes, hospital and ED use and were linked through the Honest Broker Service. PwD were identified through dementia medication and through causes for hospital admissions and death. RESULTS: Dementia was associated with increased risk of hospital admissions and ED visits, and with lower odds of hospital readmission. Significant predictors for hospital admissions and readmissions in PwD were transitioning to a care home, living in urban areas and being widowed, while female gender and living in less deprived areas reduced the odds of admissions. Older age and living in less deprived areas were associated with lower odds of an ED visit for PwD. In contrast to predictions, mortality rates were lower for PwD following a hospital admission or ED visit. CONCLUSIONS: These findings result in a better understanding of hospital and ED use for PwD. Surprisingly, survival for PwD was prolonged following hospital admissions and ED visits and thus, policies and services enabling these visits are necessary, especially for people who live alone or in rural areas; however, increased primary care and other methods, such as eHealth, could provide equally effective care in order to avoid distress and costs for hospital admissions and ED visits.

Effect of follicular aspiration just before ovulation on corpus luteum characteristics, circulating progesterone concentrations and uterine receptivity in single-ovulating and superstimulated heifers.

The aim of this study was to investigate, in unstimulated and superstimulated heifers, the effect of follicle aspiration just before ovulation on corpus luteum (CL) development, circulating progesterone (P(4)) concentrations and the ability of the uterus to support embryo development. Following follicle aspiration or ovulation timed from GNRH administration, CL development was assessed by daily ultrasonography, and CL function was assessed in terms of the capacity to produce P(4) and the expression of genes involved in steroidogenesis in luteal tissue. The capacity of the uterine environment to support conceptus development was assessed following transfer and recovery of in vitro-produced embryos. Follicular aspiration just before the expected time of ovulation leads to a significant reduction in CL diameter, CL area and area of luteal tissue. This was associated with a decrease in circulating P(4) in both unstimulated and superstimulated heifers. Follicle aspiration leads to a reduction in conceptus length and area on day 14 in unstimulated heifers only. Follicle aspiration leads to a reduction in the expression of LHCGR in luteal tissue from unstimulated heifers compared with those in which the CL formed after ovulation. Superstimulation significantly reduced the expression of STAR in luteal tissue in both ovulated and follicle-aspirated heifers. In conclusion, in stimulated and unstimulated heifers, aspiration of the preovulatory dominant follicle(s) just before expected ovulation interferes with the subsequent formation and function of the CL, in terms of size and P(4) output and this, in turn, is associated with a reduced capacity of the uterus to support conceptus elongation in unstimulated heifers.

The association between metabolic parameters and oocyte quality early and late postpartum in Holstein dairy cows.

The objective of this was to study the association between metabolic parameters and oocyte quality in postpartum lactating dairy cows as assessed by oocyte morphology and development after fertilization and culture in vitro. Holstein-Friesian spring-calving cows were used (n = 16, parity 3.0 ± 0.36, weight at calving 611 ± 16.2 kg, previous 305-d milk yield 6,454.0 ± 276.4 kg). Bodyweight (BW) and body condition score were recorded at approximately 2 wk before expected calving date, at calving, and then weekly until the end of the experiment (approximately 80 d postpartum). Blood plasma samples were collected weekly, starting 2 wk before the expected calving date and continuing until the end of the experiment and were analyzed for nonesterified fatty acids (NEFA), ß-hydroxybutyrate (BHBA), insulin, insulin-like growth factor-I, and glucose. Transvaginal oocyte recovery was carried out twice weekly on each cow for a period of approximately 12 wk starting 14 d after calving until approximately 80 d postpartum. A linear decrease in BW was observed from calving (d 0) to d 28, after which it remained stable. Body condition score decreased from 14 d precalving, reaching a nadir at approximately d 35 to 42, after which it increased to the end of the period. Nonesterified fatty acid concentrations were significantly elevated from the week before calving until d 42 postcalving, whereas BHBA concentration was significantly elevated from calving to d 49 postcalving. Insulin-like growth factor-I concentration dramatically decreased from d -14 to a nadir on d 7. A significant increase in glucose concentration occurred from d -7 to d 0, followed by a precipitous decrease to d 7. Based on the metabolic profiles (particularly NEFA and BHBA concentrations), data from d 0 to 42 postpartum (period 1) were compared with corresponding data from d 42 to 80 (period 2). Apart from body condition score, all of the physiological parameters measured (milk yield, BW, and blood metabolites) differed significantly between the 2 periods. In particular, insulin-like growth factor-I, insulin, and glucose concentrations were higher post-d 42, whereas BHBA and NEFA were lower compared with pre-d 42 postpartum. The number of oocytes recovered per session and oocyte quality grade did not differ between periods. Positive associations of follicles aspirated and insulin, BHBA, and NEFA were detected. The number of oocytes recovered was positively associated with milk yield, BW, and glucose and NEFA concentrations. The number of cleaved oocytes was positively associated with BW and NEFA concentration. In conclusion, the data do not provide evidence of an effect of lactation-induced metabolic stress on oocyte developmental competence in the postpartum dairy cow assessed in terms of morphological quality and ability to develop following in vitro fertilization.

Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA.

BACKGROUND: Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria. AIM: The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital. METHODS: This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden. FINDINGS: Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient. CONCLUSION: CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.

Eating disorder services for young people in Ireland: perspectives of service providers, service users and the general adolescent population.

OBJECTIVES: This paper illuminates how national eating disorder (ED) policy translates into day-to-day practice by exploring how ED services are experienced by those who deliver and use them. METHODS: A mixed-methods approach was used, which combined qualitative and quantitative techniques. The paper collates data from three studies: (i) an interview study exploring the lived experiences of young people with EDs (n=8), their parents (n=5) and their healthcare professionals (n=3); (ii) a national survey of health professionals' perspectives on existing ED services (n=171); (iii) a nationwide survey of secondary-school students' eating concerns and patterns of help-seeking (n=290). RESULTS: The qualitative interviews with young people and their parents revealed feelings of isolation and helplessness. Young people expressed interest in patient support groups, while parents desired greater support for the family unit. Parents were highly critical of available services, particularly in relation to access. These criticisms were echoed in the survey of healthcare professionals, who reported many barriers to delivering effective care. Clinicians were almost unanimous in calling for care pathways to be clarified via a standardised treatment protocol. The survey of adolescents indicated widespread reluctance to seek help regarding eating concerns: over one-third expressed concern about their own eating habits, but half of these had not divulged their concerns to anyone. Participants' preferred pathways of help-seeking revolved around family and friends, and adolescents were unsure about routes of access to professional support. CONCLUSIONS: The research demonstrates that many aspects of national ED policy have not been implemented in practice. The paper highlights specific gaps and suggests ways they can be redressed.

Infection control and tuberculosis in health care workers: an assessment of 28 hospitals in South Africa.

SETTING: Twenty-eight public hospitals in the Free State Province, South Africa. OBJECTIVE: To examine the association between tuberculosis (TB) infection control (IC) scores in Free State hospitals and the incidence of TB disease among health care workers (HCWs) in 2012. DESIGN: A cross-sectional survey and mixed-methods analysis of TB IC policies, practices and infrastructure using a comprehensive, 83-item IC audit and observation tool. RESULTS: As the total IC score increased, the probability of TB in an HCW at that hospital decreased. When adjusted for other covariates in multivariate analysis, if the total score of a hospital increased by one unit, the odds of an HCW having TB decreased by 4.9% (95%CI 0.9-8.8). Significant associations were also seen for the personal protective equipment (PPE) score, where odds decreased by 11.5% (95%CI 1.8-20.1) for each unit increase in score. Administrative score, environmental score and miscellaneous score were not statistically significant in the multivariate model. CONCLUSIONS: These findings reaffirm that overall IC and PPE are essential to protect HCWs from acquiring TB. More attention to TB IC is required to protect the health care workforce and to stop the South African TB epidemic.

Occupational tuberculosis in South Africa: are health care workers adequately protected?

Setting: A provincial tertiary hospital in Gauteng province, South Africa, with a high burden of tuberculosis (TB) patients and high risk of TB exposure among health care workers (HCWs). Objective: To determine HCWs' adherence to recommended TB infection prevention and control practices, TB training and access to health services and HCW TB rates. Design: Interviews with 285 HCWs using a structured questionnaire as part of a large, international mixed-methods study. Results: Despite 10 HCWs (including seven support HCWs) acquiring clinical TB during their period of employment, 62.8% of interviewees were unaware of the hospital's TB management protocol. Receipt of training was low (34.5% of all HCWs and <5% of support HCWs trained on TB transmission; 27.5% of nurses trained on respirator use), as was use of respiratory protection (44.5% of HCWs trained on managing TB patients). Support HCWs were over 36 times more likely to use respiratory protection if trained; nurses who were trained were approximately 40 times more likely to use respirators if they were readily available. Conclusion: Improved coordination and uptake of TB infection prevention training is urgently needed, especially for non-clinical HCWs in settings of regular exposure to TB patients. Adequate supplies of appropriate respiratory protection must be made available.

Contexte : Un hôpital provincial de niveau tertiaire dans la province de Gauteng, Afrique du Sud avec de très nombreux patients avec tuberculose (TB) et un risque élevé d'exposition à la TB parmi les travailleurs de santé (HCW).Objectif : Déterminer l'observance des HCW vis-à-vis des pratiques recommandées de prévention de l'infection et de lutte contre la TB, la formation en matière de TB et l'accès aux services de santé, et le taux de TB chez les HCW.Schéma : Entretiens avec 285 HCW, basés sur un questionnaire structuré, dans le cadre d'une vaste étude internationale à multiples méthodes.Résultats : Bien que 10 HCW (dont sept personnels de soutien) aient eu une TB pendant leur période de travail, 62,8% des répondants n'étaient pas au courant du protocole de prise en charge de la TB dans l'hôpital. La couverture de la formation a été faible (34,5% de tous les HCW et moins de 5% des HCW de soutien sur la transmission de la TB ; 27,5% des infirmiers sur l'utilisation d'un masque respiratoire), tout comme l'utilisation d'une protection respiratoire (44,5% des HCW prenant en charge des patients TB). Les HCW de soutien ont été 36 fois plus susceptibles d'utiliser une protection respiratoire s'ils avaient été formés ; les infirmiers qui avaient été formés ont été environ 40 fois plus susceptibles d'utiliser des masques respiratoires s'ils étaient facilement disponibles.Conclusion : Une amélioration de la coordination et de la couverture de la formation à la prévention de l'infection TB est requise d'urgence, surtout pour les HCW de soutien dans les contextes d'exposition régulière aux patients TB. Des stocks suffisants de protection respiratoire doivent être disponibles.

Marco de referencia: Un hospital provincial de atención terciaria en la provincia de Gauteng de Suráfrica, donde se observa una alta carga de morbilidad por tuberculosis (TB) y un alto riesgo de exposición de los profesionales de salud (HCW) a la enfermedad.Objetivo: Evaluar la observancia de las prácticas de prevención y control de la infección tuberculosa, la capacitación en materia de TB y el acceso de los HCW a los servicios de atención y calcular la tasa de TB en este tipo personal.Método: Se entrevistaron 285 HCW mediante un cuestionario estructurado, en el marco de un extenso estudio internacional por métodos mixtos.Resultados: Pese a que 10 HCW (incluidos siete miembros del personal auxiliar) habían adquirido la enfermedad tuberculosa durante el período de su empleo, el 62,8% de los entrevistados no conocía el protocolo de manejo de la TB del hospital. La tasa de capacitación era baja (34,5% de todos los HCW y menos de 5% del personal auxiliar sobre la transmisión de la TB y 27,5% del HCW sobre la utilización de mascarillas respiratorias) y asimismo la utilización de la protección respiratoria (el 44,5% de los HCW que se ocupaban de pacientes con TB). La probabilidad de que personal auxiliar utilizara la protección respiratoria era 36 veces mayor al haber recibido capacitación; el personal de enfermería tenía una probabilidad 40 veces mayor de utilizar las mascarillas respiratorias cuando había sido formado y el material estaba al alcance.Conclusión: Se precisa con urgencia una mejor coordinación y una utilización más amplia de la formación sobre la prevención de la infección tuberculosa, sobre todo dirigida a los HCW auxiliares, en los entornos donde es corriente la exposición a pacientes tuberculosos. Es necesario contar con los suministros adecuados de protección respiratoria al alcance del personal.

Stigma and treatment of eating disorders in Ireland: healthcare professionals' knowledge and attitudes.

OBJECTIVES: This study examines aspects of healthcare professionals' knowledge and attitudes about eating disorders (EDs), which might impede the effective detection or treatment of EDs in Ireland. METHODS: A total of 1,916 healthcare professionals were invited to participate in a web-based survey. Participants were randomly allocated to view one of five vignettes depicting a young person with symptoms consistent with anorexia nervosa, bulimia nervosa, binge-eating disorder, depression or type 1 diabetes. Study-specific questions examined participants' responses to the vignettes and ED knowledge and experience. RESULTS: In total, 171 clinicians responded (9% response rate). Participants had an average of 15.8 years of clinical experience (s.d.=9.2) and included psychiatrists, GPs, psychologists and counsellors. Although participants' knowledge of EDs was moderately good overall, responses showed poor recognition of the symptoms of EDs compared with depression [χ 2 (4, n=127)=20.17, p<0.001]. Participants viewed EDs as chronic disorders that primarily affected females. Participants believed that clinicians like working with patients with depression and diabetes more than with AN patients [F (4,101)=5.11, p=0.001]. Among the professionals surveyed, psychiatrists were the most knowledgeable about EDs [F (4,82)=9.18, p<0.001], and were more confident in their ability to diagnose and treat EDs than professionals of all other disciplines, except psychologists [F (4,85)=8.99, p<0.001]. Psychiatrists were also the most pessimistic about ED patients' long-term life prospects [χ 2 (4, n=65)=15.84, p=0.003]. CONCLUSIONS: This study recommends that specific attention should be given to EDs in professional educational programmes across healthcare disciplines. This training should not be restricted to improving healthcare professionals' knowledge of EDs, but should also strive to increase service-providers' awareness of how their own potentially stigmatising attitudes can undermine engagement with treatment.

Pilot study to detect airborne Mycobacterium tuberculosis exposure in a South African public healthcare facility outpatient clinic.

BACKGROUND: Airborne transmission of Mycobacterium tuberculosis remains an occupational health hazard, particularly in crowded and resource-limited healthcare settings. AIM: To quantify airborne M. tuberculosis in a busy outpatient clinic in Gauteng, South Africa. METHODS: Stationary air samples and samples from healthcare workers (HCWs) were collected in the polyclinic and administrative block. Quantitative real-time polymerase chain reaction (PCR) was used to detect airborne M. tuberculosis. Walkthrough observations and work practices of HCWs were also recorded. FINDINGS: In total, M. tuberculosis was detected in 11 of 49 (22.4%) samples: nine of 25 (36%) HCW samples and two of 24 (8.3%) stationary air samples. Samples from five of 10 medical officers (50%) and three of 13 nurses (23%) were positive. Repeat measurements on different days showed variable results. Most of the HCWs (87.5%) with positive results had been in contact with coughing patients and had not worn respiratory masks despite training. CONCLUSION: The use of air sampling coupled with quantitative real-time PCR is a simple and effective tool to demonstrate the risk of M. tuberculosis exposure. The findings provide an impetus for hospital management to strengthen infection prevention and control measures for tuberculosis.

Ex vivo release of GABA from tetanus toxin-induced chronic epileptic foci decreased during the active seizure phase.

Injecting a few mouse LD(50) of tetanus toxin into rat hippocampus has been shown to induce a remarkably persistent sequence of functional changes which provide a chronic model of limbic epilepsy. Here we have measured the release of amino acid transmitters evoked by K(+)-stimulation from hippocampal slices prepared from rats which had been injected 10-14 days previously with 6 mouse LD(50) (c. 3 ng) of tetanus toxin. The Ca(2+)-dependent component of the release of [(14)C]?-aminobutyric acid (GABA) was depressed to two thirds its control level. Rats which had survived 6-8 weeks, by which time the seizures had ceased, showed a recovery of the Ca(2+)-dependent component of the K(+)-evoked release of GABA to control levels, but these rats also exhibited a paradoxical depression of the Ca(2+)-independent component of release. [(3)H]d-Aspartate has previously been used as a putative marker for excitatory amino acid release. However, it failed to fulfil this role in the present study because its release was not stimulated by K(+). In contrast [(3)H]d-aspartate was released in response to veratrine. Together with previous work this suggests that while [(3)H]d-aspartate was taken up into neurones, it did not enter the releasable vesicular pool. HPLC measurements of the release of endogenous excitatory amino acids showed that glutamate (and not aspartate) was stimulated by K(+) in a Ca(2+)-dependent manner, and that the amount of release did not differ in the tetanus toxin-injected rats. The depression of GABA release provides the most likely mechanism for the seizures. The recovery of its Ca(2+)-dependent release provides the most likely basis for seizure remission after 6-8 weeks, in this chronic epileptic syndrome.

Far lateral lumbar disc herniation. The key to the intertransverse approach.

Of a total of 330 patients requiring operation on a lumbar disc, 20 (6.1%) with lateral disc prolapse had a new muscle-splitting, intertransverse approach which requires minimal resection of bone. There were 16 men and 4 women with a mean age of 52 years. All had intense radicular pain, 15 had femoral radiculopathy and 19 a neurological deficit. Far lateral herniation of the disc had been confirmed by MRI. At operation, excellent access was obtained to the spinal nerve, dorsal root ganglion and the disc prolapse. The posterior primary ramus was useful in locating the spinal nerve and dorsal root ganglion during dissection of the intertransverse space. At review from six months to four years, 12 patients had excellent results with no residual pain and six had good results with mild discomfort and no functional impairment. Two had poor results. There had been neurological improvement in 17 of the 20 patients. We report a cadaver study of the anatomy of the posterior primary ramus. It is readily identifiable through this approach and can be traced down to the spinal nerve in the intertransverse space. We recommend the use of a muscle-splitting intertransverse approach to far lateral herniation of the disc, using the posterior primary ramus as the key to safe dissection.

Displaced supracondylar fractures of the humerus in children. Audit changes practice.

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assessed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries.

Cross-linked polyethylene and bisphosphonate therapy for osteolysis in total hip arthroplasty: a case report.

A 39-year-old woman underwent bilateral total hip arthroplasty with conventional, ethylene oxide-sterilised liners when she was a subject in a radiostereometric analysis study. Within 2 years she had rapid polyethylene wear with aggressive, asymptomatic, and periprosthetic osteolysis on both sides. Oral alendronate therapy halted the progression of osteolysis over a year and revision to cross-linked polyethylene liners was then undertaken while one stem was curettaged and the other revised. Radiostereometric analysis revealed a 96% reduction in wear rate over 2 years with the cross-linked liners. On stopping alendronate treatment, aggressive osteolysis recurred on the curretaged but not on the revised femur.

The relationship between in vivo limb and in vitro tendon mechanics after injury: a potential novel clinical tool for monitoring tendon repair.

REASONS FOR PERFORMING THE STUDY: Highly prevalent superficial digital flexor tendon (SDFT) injury results in compromised tendon function through fibrosis and high frequency of re-injury due to altered biomechanical function. This study investigated the consequences of SDF tendinopathy on limb mechanics in relation to the mechanical properties of injured tendon. OBJECTIVES: To develop and validate a noninvasive in vivo assessment of tendon mechanics to investigate the effect of recent SDFT injury on limb stiffness index, providing an objective method to assess quality of healing. HYPOTHESES: Limb stiffness index would reduce as a consequence of SDFT injury and progressively increase during tendon healing and correlate with in vitro mechanical properties of the respective SDFTs. METHODS: Kinematic analysis was performed at walk in 10 horses that had sustained career-ending SDFT injury. Stiffness index was derived from limb force recorded via a series of force plates and measurement of change in metacarpophalangeal joint angle using 3D motion analysis software. Horses were subjected to euthanasia 7 months after injury, the SDFTs removed and subjected to nondestructive in vitro mechanical testing. RESULTS: Limb stiffness index was reduced following SDFT injury in comparison with the contralateral limb and increased during the convalescent period, approximating that of the contralateral limb by 7 months post injury. There was a significant positive correlation between in vivo limb stiffness index and in vitro SDFT stiffness. CLINICAL RELEVANCE: The ability to assess and monitor SDFT mechanical competence through limb stiffness measurement techniques in horses recovering from SDFT injury and the possibility of corroborating this with functional tendon healing may permit a more objective and accurate assessment of optimal tendon repair in the horse. This technique may be a useful method for assessing the efficacy of treatment regimens for tendinopathy and could be utilised to predict time to safe return to performance or re-injury.