Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study.

PURPOSE: CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma. METHODS: Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. "Unsuspected injuries" defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated. RESULTS: Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%). CONCLUSION: Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.

Treatment of congenital clasped thumb in arthrogryposis.

We report the result of treatment of 69 complex clasped thumbs in 39 patients with distal arthrogryposis. The mean age at surgery was 30 months. Surgical reconstruction included skin augmentation of the first web using modified dorsal rotation advancement flap (Abdel-Ghani flap), a la Carte release of tight structures of the first web, and chondrodesis of the thumb metacarpophalangeal joint. The mean follow-up was 4 years. We prefer chondrodesis because of the presence of global instability, abnormal joint structure, abnormal articular surfaces, and inefficient muscles for transfer. Also, chondrodesis shortens the thumb and may alleviate the need for release of deficient palmar skin and lengthening of a short flexor pollicis longus. The Abdel-Ghani flap provides ample skin that gives a wide rounded web. It is a simple procedure with minimal donor site morbidity. Surgical reconstruction significantly improved the cosmetic appearance and function of the thumb. LEVEL OF EVIDENCE: IV.

The anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis by modified Dunn subcapital osteotomy using the Ganz approach: functional and radiological outcomes.

AIMS: This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz. PATIENTS AND METHODS: We prospectively studied 31 patients (32 hips; 16 females and five males; mean age 14.3 years) with SCFE. On the Southwick classification, ten were of moderate severity (head-shaft angle > 30° to 60°) and 22 were severe (head-shaft angle > 60°). Each underwent open reduction and internal fixation using an intracapsular osteotomy through the physeal growth plate after safe surgical hip dislocation. Unlike the conventional procedure, 25 hips did not need an osteotomy of the apophysis of the great trochanter and were managed using an extended retinacular posterior flap. RESULTS: Clinical outcome was assessed using the range of movement and the Harris Hip (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC), and Merle d'Aubigné scores, while radiological measurements included slip and alpha angles. The mean duration of follow-up was 24.1 months (12 to 40). There was a significant improvement in all clinical and radiological measurements after treatment (p < 0.001). Post-operative major complications were one deep infection and one case of femoral head collapse. CONCLUSION: These findings suggest that a modified Dunn osteotomy carried out through Ganz approach is a safe and effective method of treating the stable SCFE with a high degree of slip. Cite this article: Bone Joint J 2016;98-B:1283-8.

Tendon transfer for treatment of internal rotation contracture of the shoulder in brachial plexus birth palsy.

We retrospectively analyzed 63 patients with internal rotation contracture of the shoulder secondary to brachial plexus birth palsy treated with subscapularis sliding combined with either latissimus dorsi transfer (group A: n = 18) or latissimus dorsi and teres major transfer (group B: n = 45) to the rotator cuff. The mean age at time of surgery was 43 months (SD 21 months; range 8 months to 9 years). We used a modification of the Gilbert shoulder grading system for assessment. All patients showed statistically significant improvement of active shoulder abduction and external rotation without significant differences between the two groups. Significant external rotation contracture of the shoulder (inability to touch the abdomen with the wrist extended) occurred in 42 of 63 patients, and there was a greater incidence of external rotation contracture in group B. We conclude that surgery should be restricted to latissimus dorsi transfer without teres major transfer to avoid external rotation contractures. Our modification of the Gilbert grading system appears to be valid and applicable.

Management of stiffness following total knee arthroplasty: a systematic review.

AIM: The aim of the study was to systematically evaluate the outcome of four main modalities of treatment for arthrofibrosis that develops subsequent to a total knee arthroplasty (TKA), namely manipulation under anesthesia (MUA), arthroscopic debridement, open surgical release and revision TKA. MATERIALS AND METHODS: A computerised search was conducted for relevant studies published from 1975 onwards in all the major databases and various search engines. A total of twenty-five studies were selected, representing a total of 798 patients. Studies that passed the inclusion criteria were then subjected to quality assessment using the Newcastle-Ottawa Scale. On assessment, the 25 studies scored a total of 77 stars out of a possible 125. Two studies were prospective in design, while the remaining case series were retrospective in nature. The primary outcome measures assessed were increase in range of movement (ROM) and the Knee Society Score (KSS) at final follow-up. RESULTS: Our results showed that manipulation under anesthesia (MUA) had a mean increase in ROM of 38.4°, arthroscopic release had a mean increase of 36.2°, open surgical release had a mean increase of 43.4° and revision TKA had a mean increase of 24.7°. No significant differences were found in the KSS of the four treatment modalities. Our analysis suggests that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery if their lifestyle requires a higher ROM for activities of daily living. However, there were methodological limitations as majority of the papers were case series, which decreased the quality of the evidence available.

Optimization of Toxoplasma gondii cultivation in VERO cell line.

In vitro culture of Toxoplasma gondii can provide tachyzoites which are active, viable and with desirable purity. Thus the aim of this study was to optimize the cell culture method for T. gondii propagation to obtain a consistent source of parasites with maximum yield and viability, but minimum host cell contamination for use in production of excretory-secretory antigen. Tachyzoites with seed counts of 1x10(6), 1x10(7) and 1x10(8) harvested from infected mice were added to VERO cells of different degrees of confluence, namely 50%, 85% and 100%, and examined periodically using an inverted microscope. When the maximum release of the tachyzoites was observed from the host cells, the culture supernatant was removed and the tachyzoites harvested. Using a Neubauer chamber, the percentages of viable tachyzoites and host cell contamination were determined using trypan blue stain. Parameters that gave the best yield and purity of viable tachyzoites were found to be as follows: VERO cells at 85% confluence in DMEM medium and inoculum comprising 1x10(7) tachyzoites. After about 3 days post infection, the tachyzoites multiplied 78x, with a yield of ~7.8x10(8) per flask, 99% viability and 3% host cell contamination. This study has successfully optimized the method of propagation of T. gondii tachyzoites in VERO cells which produce parasites with high yield, purity and viability.

Management of combined nonunion and limb-length discrepancy after vascularised fibular grafting.

We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma. Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems.

Crisis into opportunity: setting up community mental health services in post-tsunami Aceh.

The Asian Tsunami killed more than 130,000 people and made 400,000 homeless in Aceh, an area in Indonesia already affected by over thirty years of conflict. This paper examines an approach taken by an International Non-Governmental Organisation (INGO) to address emergency mental health and psychosocial needs in an integrated way, by providing a continuum of care incorporating psychosocial support for the wider community and clinical services for the more severely affected. The model included outreach to the indigenous system. Psychosocial activities were developed in partnership with the local communities. Community-based clinical mental health services were established by identifying and building locally-based capacity at the primary health care level, and potentially sustainable services were established in collaboration with the Ministry of Health. By December 2005, four hundred and eighty three patients had been seen. More than one third suffered from serious mental disorders that predated the Tsunami. Thus, crisis provided an opportunity to address longstanding community mental health needs. The lessons learned from this approach are also discussed.

Modified dorsal rotation advancement flap for release of the thumb web space.

The dorsal rotational advancement flap described by Buck-Gramcko in 1998 is a good local flap for release of the thumb index web space. This paper describes a modification which broadens the apex of the flap and increases its length. This modification provides a long wide flap which releases the thumb index web space with suture lines far beyond the web. In addition, it provides a release of the palmar skin even when very tight in severe narrowing of the web. It is suitable for release of thumb-index syndactyly, severe narrowing of the web in thumb hypoplasia and congenital clasped thumb.

Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation.

We treated 30 tibial plateau fractures (Schatzker Type VI) in 29 patients, with a mean age of 41.4 (20-76) years, with the Ilizarov fixator. In 18 fractures, we combined the treatment with minimal internal fixation. All fractures were the result of high-energy trauma, and 20 patients had associated injuries. Twenty-eight fractures were available for follow-up after 27 (16-36) months. Using The Knee Society clinical rating system, 18 knees were rated as excellent, seven as good, one as fair, and two as poor. There was a direct correlation between the presence of associated injuries and the final outcome. The most significant concomitant injuries were distal femoral fractures and extensive soft-tissue injury. This study emphasizes the clinical success and low morbidity associated with the use of external fixation and minimal internal fixation.

Correction of relapsed or neglected clubfoot using a simple Ilizarov frame.

We present the results of using a simple Ilizarov fixator frame in treatment of 66 feet in 52 patients (mean age 8.5 years) of 58 relapsed and eight neglected clubfeet with grade III or IV severity with a mean follow-up of 40 (26-58) months. Our frame, in spite of being simple and easy for surgeons and patients to handle, achieved satisfactory correction comparable to the literature.

Evaluation of vascular access complications in acute and chronic hemodialysis.

PURPOSE: This work aimed to determine the incidence of vascular access (VA)-related complications of temporary venous catheters in acute hemodialysis (HD) prescription, to study the survival rate of chronic HD patients who began HD with a catheter insertion and to evaluate associated complications. METHODS: The patients were classified into two groups. Group I, patients in whom venous catheters were inserted (652 patients). Group II, 80 patients with end-stage renal disease (ESRD) in whom an arteriovenous fistula (AVF) was established. RESULTS: Complications in the femoral approach were bleeding from a femoral artery wall laceration in only 6/600 patients (1%), successfully repaired in all patients, bleeding from a punctured femoral artery in 30 patients (5%), the incidence of infection and removal was 40%. Other complications included groin hematoma in 3 patients (0.5%) and catheter thrombosis in 45 patients (7.5%). In the jugular vein approach, infection occurred in 6/30 patients (20%), thrombosis in 9 patients (30%), and accidental withdrawal in 2 patients (6.7%). In the subclavian vein approach, catheter dysfunction was found in 7/22 patients (32%), infection in 10 patients (45.5%), and failure to cannulate the vein in 3 patients (13.6%). In group II, limb edema was found in 14/80 patients (17.5%), hematoma in 5 patients (6.3%), accidental trauma to the fistula in 2 patients (2.5%) and fistula stenosis in 15 patients (18.8%). Patients who began HD with a catheter had higher mortality than those who began with an AVF (12 months survival, respectively, 60 vs. 83%). CONCLUSION: Patients who began HD with a catheter had more complications and higher mortality. Routine quality assessment of AVF by Doppler ultrasound is recommended.

Hypertension among attendants of primary health care centers in Al-Qassim region, Saudi Arabia.

OBJECTIVE: The aims of the present work were to determine the prevalence of hypertension among attendants of primary health care centers in Al-Qassim region, Kingdom of Saudi Arabia. Also to investigate sociodemographic associates, and assess awareness among hypertensives. METHODS: Through cluster sampling 30 primary health care centers were selected. Forty attendants were chosen randomly from each center. A questionnaire inquiring sociodemographic characteristics and awareness was completed by interview with each participant. Using standardized methods the blood pressure, height and weight were measured. RESULTS: The study sample amounted to 1114 persons, 338 (30%) were hypertensives (blood pressure >140/90), 24% stage 1, 4% stage 2 and 2.5% stage 3. The prevalence increased with age. It was higher in males (33%), single persons (44%), illiterate (33%), merchants (45%) and obese persons (35%). Age above 40 years, illiteracy, overweight and obesity were independently associated with hypertension with statistically significant value. Less than one 4th (23%) of hypertensives were aware of their hypertension. CONCLUSION: Hypertension is a major public health problem. A routine measurement of blood pressure of all attendants of primary health care centers with periodic examination of those aged more than 40 years particularly overweight and obese persons should be implemented.

Peak expiratory flow rate in a sample of normal saudi males at riyadh, saudi arabia.

OBJECTIVE: To find out the normal peak expiratory flow rate for adult Saudi males and to compare our standards with British standards. METHODS: A cross-sectional study was carried out in five primary health care centers representing Riyadh city in the period between 15(th) November through December 1993. Six hundred and eighty Saudi men who satisfied stringent criteria of normality were included in the study. RESULTS: The mean and standard deviation of the subjects' age and height were 28.4 ± 13 and 167.6 ± 6.4 respectively. Linear regression analysis was performed through step-wise procedure to determine the form of regression of peak expiratory flow on age and height. Regression curves were obtained and it was found that peak expiratory flow rate did not begin to decline until about the age of 25 years; and as height increased the peak expiratory flow rate increased in a linear relationship. CONCLUSION: It was demonstrated that our study group had lower peak expiratory flow rate compared with British people. These findings will serve as a basis for preparing flow rate values for our population.

Chromatographic separation of pigments produced by Arthroderma benhamiae.

Variations in pigment production under different cultural conditions have limited the usefulness of pigmentation for identifying strains of Arthroderma benhamiae. If culture conditions are constant, pigmentation by individual strains is reproducible, and may be extracted and separated by thin layer chromatography. This allows recognition of pigment similarities which may be masked in whole colonies, thereby greatly enhancing the value of pigmentation in strain identification.